2. 2. Unless indicated by my checking the “YES” box next to an item below, I have checked the “NO” box to indicate that neither I nor any other member of my household have a history of violent or abusive conduct including the following:

Check YES to all that apply	Check NO to all that DO NOT apply		Self	Other household member	Date
YES|	NO	A finding of abuse by a Children & Youth Agency or similar agency in Pennsylvania or similar statute in another jurisdiction
YES|	NO|	Abusive conduct as defined under the Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction
YES|	NO|	Other:

YES□

NO□

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□

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YES□

NO□

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Other:

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YES□

NO□

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3. Please list any evaluation, counseling or other treatment received following conviction or finding of abuse:
4. If any conviction above applies to a household member, not a party, state that person's name, date of birth, and relationship to the child:
5. If you are aware that the other party or members of the other party’s household has or have a criminal record/abuse history, please explain: