[ { "page": 1, "items": [ { "page": 1, "type": "TITLE", "location": { "l": 82.56, "t": 742.08, "r": 529.2, "b": 713.52 }, "text": "IN THE COURT OF COMMON PLEAS FOR ADAMS COUNTY, PENNSYLVANIA\nCIVIL ACTION - LAW", "reading_order": 0, "level": 1 }, { "page": 1, "type": "TEXT", "location": { "l": 81.84, "t": 695.76, "r": 514.56, "b": 668.48 }, "text": "Name PLAINTIFF CASE NO.", "reading_order": 1 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 86.4, "t": 714.24, "r": 284.4, "b": 687.72 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "Name1(CRAHV)", "pdf_field_type": "Text", "reading_order": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 81.84, "t": 668.48, "r": 514.56, "b": 641.2 }, "text": "vs. : ACTION IN CUSTODY", "reading_order": 3 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 397.44, "t": 672.84, "r": 505.44, "b": 646.32 }, "text": "Case No.", "field_kind": "text", "label": "Case No.", "pdf_field_name": "CaseNo(CRAHV)", "pdf_field_type": "Text", "reading_order": 4 }, { "page": 1, "type": "TEXT", "location": { "l": 81.84, "t": 641.2, "r": 514.56, "b": 613.92 }, "text": "Name DEFENDANT 1 :", "reading_order": 5 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 86.4, "t": 645.24, "r": 284.4, "b": 618.72 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "Name2(CRAHV)", "pdf_field_type": "Text", "reading_order": 6 }, { "page": 1, "type": "TEXT", "location": { "l": 81.84, "t": 613.92, "r": 514.56, "b": 586.64 }, "text": "and (if applicable) : :", "reading_order": 7 }, { "page": 1, "type": "TEXT", "location": { "l": 81.84, "t": 586.64, "r": 514.56, "b": 559.36 }, "text": ": :", "reading_order": 8 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 86.4, "t": 576.24, "r": 284.4, "b": 549.72 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "Name3(CRAHV)", "pdf_field_type": "Text", "reading_order": 9 }, { "page": 1, "type": "TEXT", "location": { "l": 81.84, "t": 559.36, "r": 514.56, "b": 532.08 }, "text": "Name DEFENDANT 2 :", "reading_order": 10 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 48.48, "t": 468.96, "r": 392.88, "b": 453.6 }, "text": "CRIMINAL RECORD / ABUSE HISTORY VERIFICATION", "marker": "□", "list_id": "L1", "level": 0, "reading_order": 11 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 50.4, "t": 475.56, "r": 64.92, "b": 456.96 }, "text": "□ CRIMINAL RECORD / ABUSE HISTORY VERIFICATION", "field_kind": "checkbox", "label": "□ CRIMINAL RECORD / ABUSE HISTORY VERIFICATION", "pdf_field_name": "Checkbox1(CRAHV)", "pdf_field_type": "CheckBox", "reading_order": 12 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 48.72, "t": 441.36, "r": 525.6, "b": 426 }, "text": "☐ REPORT OF CHILD ABUSE AND PROTECTIVE SERVICES REQUESTED BY THE", "marker": "□", "list_id": "L2", "level": 0, "reading_order": 13 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 50.4, "t": 447.96, "r": 64.92, "b": 429.36 }, "text": "□ REPORT OF CHILD ABUSE AND PROTECTIVE SERVICES REQUESTED BY THE", "field_kind": "checkbox", "label": "□ REPORT OF CHILD ABUSE AND PROTECTIVE SERVICES REQUESTED BY THE", "pdf_field_name": "Checkbox2(CRAHV)", "pdf_field_type": "CheckBox", "reading_order": 14 }, { "page": 1, "type": "TEXT", "location": { "l": 46.8, "t": 423.36, "r": 548.64, "b": 395.04 }, "text": "COURT (Court may use the first two pages of the parties’ criminal record/abuse history verification or may complete a new form.)", "reading_order": 15 }, { "page": 1, "type": "TEXT", "location": { "l": 47.76, "t": 354.96, "r": 521.76, "b": 325.92 }, "text": "1. Participants. Please list ALL members in your/the participant's household and attach sheets if necessary:", "reading_order": 16 }, { "page": 1, "type": "TEXT", "location": { "l": 48.96, "t": 315.36, "r": 561.6, "b": 299.2533 }, "text": "Name Date of Birth Address Relationship to Child(ren)", "reading_order": 17 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 51.36, "t": 284.64, "r": 177.72, "b": 271.44 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "NameRow1(CRAHV)", "pdf_field_type": "Text", "reading_order": 18 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 179.04, "t": 284.64, "r": 305.4, "b": 271.44 }, "text": "Date of Birth", "field_kind": "text", "label": "Date of Birth", "pdf_field_name": "Date of BirthRow1(CRAHV)", "pdf_field_type": "Text", "reading_order": 19 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 306.72, "t": 284.64, "r": 433.08, "b": 271.44 }, "text": "Address", "field_kind": "text", "label": "Address", "pdf_field_name": "AddressRow1(CRAHV)", "pdf_field_type": "Text", "reading_order": 20 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 434.4, "t": 284.64, "r": 560.76, "b": 271.44 }, "text": "Relationship to Child(ren)", "field_kind": "text", "label": "Relationship to Child(ren)", "pdf_field_name": "Relationship to ChildrenRow1(CRAHV)", "pdf_field_type": "Text", "reading_order": 21 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 51.36, "t": 270.36, "r": 177.72, "b": 257.16 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "NameRow2(CRAHV)", "pdf_field_type": "Text", "reading_order": 22 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 179.04, "t": 270.36, "r": 305.4, "b": 257.16 }, "text": "Date of Birth", "field_kind": "text", "label": "Date of Birth", "pdf_field_name": "Date of BirthRow2(CRAHV)", "pdf_field_type": "Text", "reading_order": 23 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 306.72, "t": 270.36, "r": 433.08, "b": 257.16 }, "text": "Address", "field_kind": "text", "label": "Address", "pdf_field_name": "AddressRow2(CRAHV)", "pdf_field_type": "Text", "reading_order": 24 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 434.4, "t": 270.36, "r": 560.76, "b": 257.16 }, "text": "Relationship to Child(ren)", "field_kind": "text", "label": "Relationship to Child(ren)", "pdf_field_name": "Relationship to ChildrenRow2(CRAHV)", "pdf_field_type": "Text", "reading_order": 25 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 51.36, "t": 256.08, "r": 177.72, "b": 242.88 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "NameRow3(CRAHV)", "pdf_field_type": "Text", "reading_order": 26 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 179.04, "t": 256.08, "r": 305.4, "b": 242.88 }, "text": "Date of Birth", "field_kind": "text", "label": "Date of Birth", "pdf_field_name": "Date of BirthRow3(CRAHV)", "pdf_field_type": "Text", "reading_order": 27 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 306.72, "t": 256.08, "r": 433.08, "b": 242.88 }, "text": "Address", "field_kind": "text", "label": "Address", "pdf_field_name": "AddressRow3(CRAHV)", "pdf_field_type": "Text", "reading_order": 28 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 434.4, "t": 256.08, "r": 560.76, "b": 242.88 }, "text": "Relationship to Child(ren)", "field_kind": "text", "label": "Relationship to Child(ren)", "pdf_field_name": "Relationship to ChildrenRow3(CRAHV)", "pdf_field_type": "Text", "reading_order": 29 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 51.36, "t": 241.8, "r": 177.72, "b": 228.6 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "NameRow4(CRAHV)", "pdf_field_type": "Text", "reading_order": 30 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 179.04, "t": 241.8, "r": 305.4, "b": 228.6 }, "text": "Date of Birth", "field_kind": "text", "label": "Date of Birth", "pdf_field_name": "Date of BirthRow4(CRAHV)", "pdf_field_type": "Text", "reading_order": 31 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 306.72, "t": 241.8, "r": 433.08, "b": 228.6 }, "text": "Address", "field_kind": "text", "label": "Address", "pdf_field_name": "AddressRow4(CRAHV)", "pdf_field_type": "Text", "reading_order": 32 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 434.4, "t": 241.8, "r": 560.76, "b": 228.6 }, "text": "Relationship to Child(ren)", "field_kind": "text", "label": "Relationship to Child(ren)", "pdf_field_name": "Relationship to ChildrenRow4(CRAHV)", "pdf_field_type": "Text", "reading_order": 33 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 51.36, "t": 227.52, "r": 177.72, "b": 214.2 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "NameRow5(CRAHV)", "pdf_field_type": "Text", "reading_order": 34 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 179.04, "t": 227.52, "r": 305.4, "b": 214.2 }, "text": "Date of Birth", "field_kind": "text", "label": "Date of Birth", "pdf_field_name": "Date of BirthRow5(CRAHV)", "pdf_field_type": "Text", "reading_order": 35 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 306.72, "t": 227.52, "r": 433.08, "b": 214.2 }, "text": "Address", "field_kind": "text", "label": "Address", "pdf_field_name": "AddressRow5(CRAHV)", "pdf_field_type": "Text", "reading_order": 36 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 434.4, "t": 227.52, "r": 560.76, "b": 214.2 }, "text": "Relationship to Child(ren)", "field_kind": "text", "label": "Relationship to Child(ren)", "pdf_field_name": "Relationship to ChildrenRow5(CRAHV)", "pdf_field_type": "Text", "reading_order": 37 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 51.36, "t": 213.12, "r": 177.72, "b": 199.92 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "NameRow6(CRAHV)", "pdf_field_type": "Text", "reading_order": 38 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 179.04, "t": 213.12, "r": 305.4, "b": 199.92 }, "text": "Date of Birth", "field_kind": "text", "label": "Date of Birth", "pdf_field_name": "Date of BirthRow6(CRAHV)", "pdf_field_type": "Text", "reading_order": 39 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 306.72, "t": 213.12, "r": 433.08, "b": 199.92 }, "text": "Address", "field_kind": "text", "label": "Address", "pdf_field_name": "AddressRow6(CRAHV)", "pdf_field_type": "Text", "reading_order": 40 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 434.4, "t": 213.12, "r": 560.76, "b": 199.92 }, "text": "Relationship to Child(ren)", "field_kind": "text", "label": "Relationship to Child(ren)", "pdf_field_name": "Relationship to ChildrenRow6(CRAHV)", "pdf_field_type": "Text", "reading_order": 41 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 51.36, "t": 198.84, "r": 177.72, "b": 185.64 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "NameRow7(CRAHV)", "pdf_field_type": "Text", "reading_order": 42 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 179.04, "t": 198.84, "r": 305.4, "b": 185.64 }, "text": "Date of Birth", "field_kind": "text", "label": "Date of Birth", "pdf_field_name": "Date of BirthRow7(CRAHV)", "pdf_field_type": "Text", "reading_order": 43 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 306.72, "t": 198.84, "r": 433.08, "b": 185.64 }, "text": "Address", "field_kind": "text", "label": "Address", "pdf_field_name": "AddressRow7(CRAHV)", "pdf_field_type": "Text", "reading_order": 44 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 434.4, "t": 198.84, "r": 560.76, "b": 185.64 }, "text": "Relationship to Child(ren)", "field_kind": "text", "label": "Relationship to Child(ren)", "pdf_field_name": "Relationship to ChildrenRow7(CRAHV)", "pdf_field_type": "Text", "reading_order": 45 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 51.36, "t": 184.56, "r": 177.72, "b": 171.36 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "NameRow8(CRAHV)", "pdf_field_type": "Text", "reading_order": 46 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 179.04, "t": 184.56, "r": 305.4, "b": 171.36 }, "text": "Date of Birth", "field_kind": "text", "label": "Date of Birth", "pdf_field_name": "Date of BirthRow8(CRAHV)", "pdf_field_type": "Text", "reading_order": 47 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 306.72, "t": 184.56, "r": 433.08, "b": 171.36 }, "text": "Address", "field_kind": "text", "label": "Address", "pdf_field_name": "AddressRow8(CRAHV)", "pdf_field_type": "Text", "reading_order": 48 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 434.4, "t": 184.56, "r": 560.76, "b": 171.36 }, "text": "Relationship to Child(ren)", "field_kind": "text", "label": "Relationship to Child(ren)", "pdf_field_name": "Relationship to ChildrenRow8(CRAHV)", "pdf_field_type": "Text", "reading_order": 49 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 47.04, "t": 146.16, "r": 554.4, "b": 85.68 }, "text": "Party requests their residence remain confidential as they are protected by the Protection from Abuse Act, 23 Pa.C.S. § 6112, or the Domestic and Sexual Violence Victim Address Confidentiality Act, 23 Pa.C.S. §§ 6701-6713, or the Child Custody Act, 23 Pa.C.S. § 5336(b), or they are in the process of seeking protection under the same.", "marker": "□", "list_id": "L3", "level": 0, "reading_order": 50 }, { "page": 1, "type": "FORM_FIELD", "location": { "l": 50.4, "t": 153.24, "r": 64.92, "b": 134.64 }, "text": "□ Party requests their residence remain confidential as they are protected by the Protection from Abuse", "field_kind": "checkbox", "label": "□ Party requests their residence remain confidential as they are protected by the Protection from Abuse", "pdf_field_name": "Checkbox3(CRAHV)", "pdf_field_type": "CheckBox", "reading_order": 51 } ] }, { "page": 2, "items": [ { "page": 2, "type": "TEXT", "location": { "l": 47.76, "t": 699.6, "r": 487.2, "b": 684.48 }, "text": "Please list ALL members in the opposing party's household and attach sheets if necessary:", "reading_order": 0 }, { "page": 2, "type": "TEXT", "location": { "l": 49.68, "t": 674.16, "r": 561.6, "b": 657.9733 }, "text": "Name Date of Birth Address Relationship to Child(ren)", "reading_order": 1 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 51.36, "t": 643.44, "r": 177.72, "b": 630.24 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "NameRow1_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 2 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 179.04, "t": 643.44, "r": 305.4, "b": 630.24 }, "text": "Date of Birth", "field_kind": "text", "label": "Date of Birth", "pdf_field_name": "Date of BirthRow1_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 3 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 306.72, "t": 643.44, "r": 433.08, "b": 630.24 }, "text": "Address", "field_kind": "text", "label": "Address", "pdf_field_name": "AddressRow1_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 4 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 434.4, "t": 643.44, "r": 560.76, "b": 630.24 }, "text": "Relationship to Child(ren)", "field_kind": "text", "label": "Relationship to Child(ren)", "pdf_field_name": "Relationship to ChildrenRow1_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 5 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 51.36, "t": 629.16, "r": 177.72, "b": 615.96 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "NameRow2_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 6 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 179.04, "t": 629.16, "r": 305.4, "b": 615.96 }, "text": "Date of Birth", "field_kind": "text", "label": "Date of Birth", "pdf_field_name": "Date of BirthRow2_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 7 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 306.72, "t": 629.16, "r": 433.08, "b": 615.96 }, "text": "Address", "field_kind": "text", "label": "Address", "pdf_field_name": "AddressRow2_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 8 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 434.4, "t": 629.16, "r": 560.76, "b": 615.96 }, "text": "Relationship to Child(ren)", "field_kind": "text", "label": "Relationship to Child(ren)", "pdf_field_name": "Relationship to ChildrenRow2_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 9 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 51.36, "t": 614.88, "r": 177.72, "b": 601.56 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "NameRow3_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 10 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 179.04, "t": 614.88, "r": 305.4, "b": 601.56 }, "text": "Date of Birth", "field_kind": "text", "label": "Date of Birth", "pdf_field_name": "Date of BirthRow3_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 11 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 306.72, "t": 614.88, "r": 433.08, "b": 601.56 }, "text": "Address", "field_kind": "text", "label": "Address", "pdf_field_name": "AddressRow3_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 12 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 434.4, "t": 614.88, "r": 560.76, "b": 601.56 }, "text": "Relationship to Child(ren)", "field_kind": "text", "label": "Relationship to Child(ren)", "pdf_field_name": "Relationship to ChildrenRow3_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 13 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 51.36, "t": 600.48, "r": 177.72, "b": 587.28 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "NameRow4_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 14 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 179.04, "t": 600.48, "r": 305.4, "b": 587.28 }, "text": "Date of Birth", "field_kind": "text", "label": "Date of Birth", "pdf_field_name": "Date of BirthRow4_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 15 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 306.72, "t": 600.48, "r": 433.08, "b": 587.28 }, "text": "Address", "field_kind": "text", "label": "Address", "pdf_field_name": "AddressRow4_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 16 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 434.4, "t": 600.48, "r": 560.76, "b": 587.28 }, "text": "Relationship to Child(ren)", "field_kind": "text", "label": "Relationship to Child(ren)", "pdf_field_name": "Relationship to ChildrenRow4_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 17 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 51.36, "t": 586.2, "r": 177.72, "b": 573 }, "text": "Name", "field_kind": "text", "label": "Name", "pdf_field_name": "NameRow5_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 18 }, { "page": 2, "type": "FORM_FIELD", "location": { "l": 179.04, "t": 586.2, "r": 305.4, "b": 573 }, "text": "Date of Birth", 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Check all that applyCrimeSelfOther household memberDate of conviction, guilty plea, no contest plea or pending chargesSentence
☐18 Pa.C.S. Ch. 25 (relating to criminal homicide)☐☐
☐18 Pa.C.S. § 2701 (relating to simple assault)☐☐
☐18 Pa.C.S. § 2702 (relating to aggravated assault)☐☐
☐18 Pa.C.S. § 2705 (relating to recklessly endangering another person)☐☐
☐18 Pa.C.S. § 2706 (relating to terroristic threats)☐☐
☐18 Pa.C.S. § 2709.1 (relating to stalking)☐☐
☐18 Pa.C.S. § 2718 (relating to strangulation)☐☐
☐18 Pa.C.S. § 2901 (relating to kidnapping)☐☐
☐18 Pa.C.S. § 2902 (relating to unlawful restraint)☐☐
☐18 Pa.C.S. § 2903 (relating to false imprisonment)☐☐
☐18 Pa.C.S. § 2904 (relating to interference with custody of children)☐☐
☐18 Pa.C.S. § 2910 (relating to luring a child into a motor vehicle or structure)☐☐
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☐18 Pa.C.S. Ch. 30 (relating to human trafficking)☐☐
☐18 Pa.C.S. § 3121 (relating to rape)☐☐
☐18 Pa.C.S. § 3122.1 (relating to statutory sexual assault)☐☐
☐18 Pa.C.S. § 3123 (relating to involuntary deviate sexual intercourse)☐☐
☐18 Pa.C.S. § 3124.1 (relating to sexual assault)☐☐
☐18 Pa.C.S. § 3125 (relating to aggravated indecent assault)☐☐
☐18 Pa.C.S. § 3126 (relating to indecent assault)☐☐
☐18 Pa.C.S. § 3127 (relating to indecent exposure)☐☐
☐18 Pa.C.S. § 3129 (relating to sexual intercourse with animal)☐☐
☐18 Pa.C.S. § 3130 (relating to conduct relating to sex offenders)☐☐
☐18 Pa.C.S. § 3301 (relating to arson and related offenses)☐☐
☐18 Pa.C.S. § 4302 (relating to incest)☐☐
☐18 Pa.C.S. § 4303 (relating to concealing death of child)☐☐
☐18 Pa.C.S. § 4304 (relating to endangering welfare of children)☐☐
☐18 Pa.C.S. § 4305 (relating to dealing in infant children)☐☐
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Check all that applyCrimeSelfOther household memberDate of conviction, guilty plea, no contest plea or pending chargesSentence
☐18 Pa.C.S. § 4304 (relating to endangering welfare of children)☐☐
☐18 Pa.C.S. § 5534 (relating to aggravated cruelty to animal)☐☐
☐18 Pa.C.S. § 5543 (relating to animal fighting)☐☐
☐18 Pa.C.S. § 5544 (relating to possession of animal fighting paraphernalia)☐☐
☐18 Pa.C.S. § 5902(b) or (b.1) (relating to prostitution and related offenses)☐☐
☐18 Pa.C.S. § 5903(c) or (d) (relating to obscene and other sexual materials and performances)☐☐
☐18 Pa.C.S. § 6301 (relating to corruption of minors)☐☐
☐18 Pa.C.S. § 6312 (relating to sexual abuse of children)☐☐
☐18 Pa.C.S. § 6318 (relating to unlawful contact with minor)☐☐
☐18 Pa.C.S. § 6320 (relating to sexual exploitation of children)☐☐
☐Finding of contempt of a Protection from Abuse order or agreement under 23 Pa.C.S. § 6114☐☐
☐Finding of contempt of a Protection of Victims of Sexual Violence and Intimidation order or agreement under 42 Pa.C.S. § 62A14☐☐
☐Driving under the influence of drugs or alcohol☐☐
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☐An adjudication of dependency involving this child or any other child under Pennsylvania's Juvenile Act, or a similar law in another jurisdiction.What jurisdiction?: ____________Is the case active?: ____________☐☐☐
☐A history of perpetrating “abuse” as that term is defined in the Protection from Abuse Act, 23 Pa.C.S. § 6102.☐☐☐
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If you checked a box in (2) or (3), list any evaluation, counseling, or other treatment received as a result:", "reading_order": 2 }, { "page": 7, "type": "LIST_ITEM", "location": { "l": 47.28, "t": 530.16, "r": 554.64, "b": 498 }, "text": "If you checked a box in (2) or (3) that applies to your household member, who is not a party, state that person's name, date of birth, and relationship to the child.", "marker": "5.", "list_id": "L6", "level": 0, "reading_order": 3 }, { "page": 7, "type": "LIST_ITEM", "location": { "l": 47.28, "t": 403.2, "r": 543.36, "b": 371.76 }, "text": "If you are aware that the other party or the other party's household member has a criminal record or abuse history, please explain.", "marker": "6.", "list_id": "L6", "level": 0, "reading_order": 4 }, { "page": 7, "type": "TITLE", "location": { "l": 46.56, "t": 261.84, "r": 549.84, "b": 234 }, "text": "ONLY A PARTY CAN SIGN THIS FORM. 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I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.", "reading_order": 6 }, { "page": 7, "type": "TEXT", "location": { "l": 51.12, "t": 145.68, "r": 178.32, "b": 136.08 }, "text": "___", "reading_order": 7 }, { "page": 7, "type": "FORM_FIELD", "location": { "l": 50.4, "t": 160.943, "r": 176.4, "b": 139.8 }, "text": "Date", "field_kind": "text", "label": "Date", "pdf_field_name": "Date(CRAHV)", "pdf_field_type": "Text", "reading_order": 8 }, { "page": 7, "type": "TEXT", "location": { "l": 48.72, "t": 140.64, "r": 485.28, "b": 121.68 }, "text": "Plaintiff/Defendant Signature", "reading_order": 9 }, { "page": 7, "type": "TEXT", "location": { "l": 48.48, "t": 136.8, "r": 178.08, "b": 123.84 }, "text": "Date", "reading_order": 10 }, { "page": 7, "type": "TEXT", "location": { "l": 263.28, "t": 140.16, "r": 484.8, "b": 81.84 }, "text": "Plaintiff/Defendant Signature\n(Printed Name)", "reading_order": 11 }, { "page": 7, "type": "FORM_FIELD", "location": { "l": 266.4, "t": 121.866, "r": 482.4, "b": 98.4 }, "text": "Printed Name", "field_kind": "text", "label": "Printed Name", "pdf_field_name": "Printed Name(CRAHV)", "pdf_field_type": "Text", "reading_order": 12 } ] }, { "page": 8, "items": [ { "page": 8, "type": "TEXT", "location": { "l": 47.04, "t": 727.44, "r": 556.32, "b": 683.76 }, "text": "I certify that this filing complies with the provisions of the Case Records Public Access Policy of the Unified Judicial System of Pennsylvania that require filing confidential information and documents differently than non-confidential information and documents.", "reading_order": 0 }, { "page": 8, "type": "TEXT", "location": { "l": 263.76, "t": 645.36, "r": 353.28, "b": 629.28 }, "text": "Signature of Filer", "reading_order": 1 }, { "page": 8, "type": "FORM_FIELD", "location": { "l": 266.4, "t": 619.92, "r": 482.4, "b": 591.12 }, "text": "Printed Name", "field_kind": "text", "label": "Printed Name", "pdf_field_name": "Printed Name_2(CRAHV)", "pdf_field_type": "Text", "reading_order": 2 }, { "page": 8, "type": "TEXT", "location": { "l": 263.76, "t": 589.2, "r": 335.04, "b": 574.56 }, "text": "Printed Name", "reading_order": 3 } ] } ]