| Check all that apply | Crime | Self | Other household member | Date of conviction, guilty plea, no contest plea or pending charges | Sentence |
| ☐ | 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) | ☐ | ☐ | | |
===== PAGE 4 =====
| Check all that apply | Crime | Self | Other household member | Date of conviction, guilty plea, no contest plea or pending charges | Sentence |
| ☐ | 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) | ☐ | ☐ | | |
===== PAGE 5 =====
| Check all that apply | Crime | Self | Other household member | Date of conviction, guilty plea, no contest plea or pending charges | Sentence |
| ☐ | 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 | ☐ | ☐ | | |
===== PAGE 6 =====
| Check all that apply | | Self | Household member | Child |
| ☐ | Involvement with a children and youth social service agency in Pennsylvania or a similar agency in another jurisdiction.What jurisdiction?: ____________ | ☐ | ☐ | ☐ |
| ☐ | A determination or finding of abuse (i.e., indicated or founded report) by a children and youth social service agency or court in Pennsylvania or a similar agency or court in another jurisdiction.What jurisdiction?: ____________ | ☐ | ☐ | ☐ |
| ☐ | 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. | ☐ | ☐ | ☐ |
| ☐ | A history of perpetrating “sexual violence” or “intimidation” as those terms are defined in 42 Pa.C.S. § 62A03 (relating to protection of victims of sexual violence and intimidation). | ☐ | ☐ | ☐ |
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4. If you checked a box in (2) or (3), list any evaluation, counseling, or other treatment received as a result:
5. 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.
6. If you are aware that the other party or the other party's household member has a criminal record or abuse history, please explain.
### ONLY A PARTY CAN SIGN THIS FORM. IF A PARTY IS REPRESENTED BY AN ATTORNEY, THE ATTORNEY CANNOT SIGN THIS FORM ON BEHALF OF THE PARTY
I verify that the information above is true and correct to the best of my knowledge, information or belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.
___
Date
Plaintiff/Defendant Signature
Plaintiff/Defendant Signature
(Printed Name)
===== PAGE 8 =====
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.
Signature of Filer
Printed Name