PRO - SE CUSTODY PACKET · PRO - SE CUSTODY PACKET Instructions For Completing The Custody Forms...

PRO - SE CUSTODY PACKET Instructions For Completing The Custody Forms All Forms Should Be Typed If Possible, Or Neatly Printed In Black Ink. This packet contains two sets of documents needed to file a Pro - Se Custody Complaint. The first set of documents has numbered blanks, which need to be filled in with the information pertaining to your particular case. This is not the set that you will file. It is only to be used as a guide to fill in the blanks on the second set. The second set has corresponding blanks, but the blanks are not numbered. This is the set that you want to complete after your participation today in the Pro - Se Custody Clinic. It is also the set that you want to file. COMPLAINT FOR CUSTODY CAPTION The first part of the Complaint For Custody is called a Caption. The Caption is a heading, which identifies a legal document. It contains the Court’s name, the type of action, the names of the parties, and the docket number. This information remains the same on each legal document filed within the same custody action. The docket number is assigned by the Court when the Complaint is filed and is used on future documents filed in the same case. (1) Plaintiff’s Name. The Plaintiff is the person initiating the custody action. Fill in your full, legal name. (2) Defendant’s Name. The Defendant is the person whom the custody action is being brought against. Fill in that person’s full, legal name. COMPLAINT (3) Fill in your full, legal name.

Paragraph 1, (4) Fill in your full, legal name. Paragraph 1, (5) Fill in your full mailing address (Name or Number of the Street or Avenue, P. O. Box Number, City, County (e.g., Mercer County), State, and Zip Code. Paragraph 2, (6) Fill in the Defendant’s full, legal name. Paragraph 2, (7) Fill in the Defendant’s full mailing address (Name or Number of the Street or Avenue, P. O. Box Number, City, County (e.g., Mercer County), State, and Zip Code.

Paragraph 3 (8) Circle the type of custody you want the court to award you. If you

are unsure what the different types of custody are, please see the

“DEFINITIONS” page attached to these instructions.

Also, list the full, legal name(s), present residence(s), and date(s)

of birth of the child(ren) involved in this case.

Paragraph 4 Circle the words, which correctly state whether the child or

children were born out of wedlock.

Paragraph 5 (9) and (10) Fill in the full, legal name(s) and address of the person(s) with whom the child or children now live with. Paragraph 6 List all the persons with whom the child(ren) (has/have) resided with during the past five years.

List all the addresses where the child(ren) (has/have) resided at during the past five years. Also, list the dates. Paragraph 7 (11) and (12) Fill in the full, legal name and address of the natural mother of the child(ren). Also, circle the marital status that applies to the mother. Paragraph 8 (13) and (14) Fill in the full, legal name and address of the natural father of the child(ren). Also, circle the marital status that applies to the father. Paragraph 9 (15) State your relationship to the child(ren) (e.g., Mother, Father, Grandmother, etc.). Paragraph 10 List everyone who now lives with you and your relationship to each of these people. Paragraph 11 (16) State the Defendant’s relationship to the child(ren) (e.g., Mother, Father, Grandmother, etc.) Paragraph 12 List everyone who now lives with the Defendant and his or her relationship with each of these people. Paragraph 13 Circle whichever phrase applies. Paragraph 14 Circle whichever phrase applies.

Paragraph 15 Circle whichever phrase applies. Paragraph 16 (17) Fill in the full, legal name(s) of the child(ren). Paragraph 16 (18) State the reasons you believe Shared Legal Custody, Sole Legal

Custody, Partial Physical Custody, Primary Physical Custody,

Shared Physical Custody, Sole Physical Custody, Supervised

Physical Custody should be awarded to you.

Paragraph 17 List any other person that you believe has a right to be a part of the

hearing concerning custody because they have standing. These

individuals must also be served with a copy of the Complaint.

Paragraph 18, (19) If you are a grandparent who is not in loco parentis to the child,

you must state facts that establish that your relationship with the

child began with the consent of a parent of the child or under court

order, that you are willing to assume responsibility for the child,

AND one of the following conditions exists: the child has been

determined to be dependent child, the child is substantially at risk

due to parental abuse, neglect, drug or alcohol abuse or incapacity,

OR the child has resided with you for 12 consecutive months (not

including brief temporary absences of the child from the home, and

is removed from the home by the parents).

Paragraph 18, (20) Complete this section if you are a grandparent seeking standing for

partial physical custody or supervised physical custody. You must

state facts that establish that EITHER (1) the parent of the child is

deceased and you are the parent of the deceased parent, (2) the

parents of the child have been separated for at least 6 months or

have started a proceeding that will dissolve their marriage, OR (3)

the child has resided with you for 12 consecutive months (not

including brief temporary absences of the child from the home, and

is removed from the home by the parents.)

Paragraph 18, (21) Complete this section if you are filing for custody because you

have acted as the child’s guardian or caretaker and have taken on

some or all of the responsibilities of a parent.

Paragraph 19 You must fill out and attached the “CRIMINAL

RECORD/ABUSE VERIFICATION” form. You must be truthful

on these forms or you could face criminal punishment.

Wherefore: Fill in which of the following that you are requesting the Court to

grant you.

(22) Sign your full, legal name

CRIMINAL RECORD / ABUSE HISTORY

You must complete and file this form with the Custody Complaint. There are two copies of this

form in this packet. You must complete one and file it with your complaint. You must include

the other blank form with the complaint when you serve the opposing party. This form may be

used by the Master and the Court during your custody proceedings.

1. Plaintiff’s name.

2. Defendant’s name

3. Your name

4. This section states that by checking any of the boxes next to a crime, you are telling the court

that either you or a household member has been convicted of, pled guilty to, or pled no contest to

that crime. You must be truthful on this form or you could be fined at least $1,000. If you are not

sure of a crime that you or a household member should list, you can visit

http://ujsportal.pacourts.us/DocketSheets/MDJ.aspx which provides access to search, view

and print the docket sheets for Pennsylvania’s courts. On this website, you should check both the

Magisterial Court Docket Sheets and the Court of Common Pleas Docket Sheet.

5. Check all that apply to either you or a household member.

6. Check all that apply to either you or a household member.

7. Again, you must be truthful! If you are not, you could face a fine of at least $1,000.

8. Sign and print your name.

VERIFICATION 1. Plaintiff’s Name 2. Defendant’s Name 3. Plaintiff’s Name 4. Plaintiff’s Signature

ORDER AND NOTICE 1. Plaintiff’s Name 2. Defendant’s Name 3. Defendant’s Name 4. Name(s) of the child/children 5. This paragraph informs the defendant that he/she must complete and file with the Court a “Criminal Record / Abuse History” form. 6. This paragraph lets the opposing party know that no party can change the child’s residence which would impair the other party’s ability to exercise custodial rights without following the required relocation procedures. ORDER APPOINTING MASTER 1. Plaintiff’s Name 2. Defendant’s Name CERTIFICATE OF SERVICE 1. Plaintiff’s Name 2. Defendant’s Name 3. Plaintiff’s Name 4. Defendant’s Name and Address. If the current address is unknown, use the last known address. 5. Plaintiff’s Signature 6. Plaintiff’s Address

CRIMINAL RECORD / ABUSE HISTORY

This blank copy should be sent to the defendant to fill out and file with the Court. Include

this blank copy when you serve the Complaint on the defendant.

IN FORMA PAUPERIS Enclosed is a separate package called an IFP, which stands for In Forma Pauperis. This is a Latin phrase, which means you do not have enough money to pay the court costs to file the Complaint For Custody. This document must be filled out and filed at the same time the Complaint is filed. FILING AND SERVICE FILING: The completed Complaint and IFP has to be filed with the Prothonotary’s Office, located on the first floor of the Court Of Common Pleas Of Mercer County, PA. Remember to make three copies of the Complaint and one copy of the IFP before filing these documents. The Office will take your Complaint and give it a docket number which will identify your case. SERVICE: A copy of the Complaint must be served on the opposing party. You must

also include the Criminal Record / Abuse History form with the Complaint. The Complaint

should be served by certified mail, return receipt requested and regular mail. You should do this

immediately after filing the Complaint.

MASTER S CONFERENCE After the Complaint has been filed and served, the Order Appointing Master will be signed by one of the judges of the Court Of Common Pleas Of Mercer County, PA. A Master is an attorney who has been appointed by the Court to hear your case. You and the opposing party will receive a copy of this Order in the mail. Subsequently, both parties will receive a hearing notice regarding the date and time for the Master’s Conference.

DEFINITIONS PLAINTIFF - the person who starts the lawsuit DEFENDANT- the person who is being sued CHILD - Any unemancipated person under 18 years of age. SHARED LEGAL CUSTODY – The right of more than one individual to legal custody of the child. SOLE LEGAL CUSTODY – The right of one individual to exclusive legal custody of the child. PARTIAL PHYSICAL CUSTODY – The right to assume physical custody of the child for less than a majority of the time. PRIMARY PHYSICAL CUSTODY – The right to assume physical custody of the child for the majority of time. SHARED PHYSICAL CUSTODY – The right of more than one individual to assume physical custody of the child, each having significant periods of physical custodial time with the child. SOLE PHYSICAL CUSTODY – The right of one individual to exclusive physical custody of the child. SUPERVISED VISITATION- Custodial time during which an agency or an adult designated by the court or agreed upon by the parties monitors the interaction between the child and the individual with those rights. NON-CUSTODIAL PARENT- the parent who has custodial rights, but with whom the child does not live with most of the time. THIRD PARTY- any person who is not a natural parent of the child IN LOCO PARENTIS – a person who has acted as a parent for a child and taken on responsibilities of parenthood for a period of time. STANDING - the legal right to be a part of a custody lawsuit BEST INTEREST OF THE CHILD - the factors which the Court looks at in deciding with whom and where the child should reside.

SAMPLE FORMS TO FOLLOW:

IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA CIVIL ACTION - LAW

(1) , : Plaintiff : : : vs. : CIVIL ACTION NO. : (2) , : Defendant : ______________________________________________________________________________

COMPLAINT FOR CUSTODY AND NOW, comes the Plaintiff, (3) ____________________________, pro-se, and

respectfully represents as follows:

1. The Plaintiff is (4) ________________________________, residing at

(5)___________________________________________________________________________.

2. The Defendant is (6) _________________________________, residing at

(7) _________________________________________________________________________.

3. The Plaintiff seeks (8) (Shared Legal Custody) (Sole Legal Custody) (Partial

Physical Custody) (Primary Physical Custody) (Shared Physical Custody) (Sole Physical

Custody) (Supervised Physical Custody) of the following child(ren):

Name Present Residence Date of Birth

______________________ _____________________ _______________

______________________ _____________________ _______________

______________________ _____________________ _______________

______________________ _____________________ _______________

4. The child(ren)(was/was not) (were/were not) born out of wedlock.

5. The child(ren)(is/are) presently in the custody of (9) _______________________

who resides at (10) _____________________________________________________________ .

6. During the past five years, the child(ren) (has/have) resided with the following

persons and at the following addresses:

Persons Addresses Dates

________________________ ______________________ ___________________

________________________ ______________________ ___________________

________________________ ______________________ ___________________

________________________ ______________________ ___________________

________________________ ______________________ ___________________

7. The mother of the child(ren) is (11) ___________________________, currently

residing at (12) ______________________________________. She is (married) (divorced)

(single).

8. The father of the child(ren) is (13) ____________________, currently residing

at (14) _________________________________________. He is (married) (divorced) (single).

9. The relationship of the Plaintiff to the child (ren) is that of (15) ______________.

10. The Plaintiff currently resides with the following persons:

Name Relationship

_______________________________ ____________________________

_______________________________ ____________________________

_______________________________ ____________________________

11. The relationship of the Defendant to the child(ren) is that of

(16) __________________________________.

12. The Defendant currently resides with the following persons:

Name Relationship

_______________________________ ___________________________

_______________________________ ___________________________

_______________________________ ___________________________

13. The Plaintiff (has) (has not) participated as a party or witness, or in another capacity, in

other litigation concerning the custody of the child(ren) in this or another court. The court, term

and number, and its relationship to this action is:

______________________________________________________________________________

_______________________________________________________________.

14. The Plaintiff (has) (has no) information of a custody proceeding concerning the

child(ren) pending in a court of this Commonwealth. The court, term and number, and its

relationship to this action is: ______________________________________________________

_______________________________________________________________.

15. The Plaintiff (knows) (does not know) of a person not a party to the proceedings

who has physical custody of the child(ren) or claims to have custodial rights with respect to the

child (ren). The name and address of such person is: ___________________________________

_____________________________________________________________ .

16. The best interest and permanent welfare of the child(ren) (17) ______________

will be served by granting the relief requested because (18) _____________________________

______________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________ .

17. Each parent whose parental rights to the child(ren) have not been terminated and

the person who has physical custody of the child(ren) have been named as parties to this action.

All other persons, named below, who are known to have or claim a right to custody of the child

will be given notice of the pendency of this action and the right to intervene:

Name Address Basis of Claim

______________________________________________________________________________ ______________________________________________________________________________

18. (a) If the plaintiff is a grandparent who is not in loco parentis to the child and is

seeking physical and/or legal custody pursuant to 23 Pa.C.S. §5323, you must plead facts

establishing standing pursuant to 23 Pa.C.S §5324(3).(19)_______________________________

______________________________________________________________________________

_____________________________________________________________________________.

(b) If the plaintiff is a grandparent or great-grandparent who is seeking partial

physical custody or supervised physical custody pursuant to 23 Pa.C.S. §5325, you must plead

facts establishing standing pursuant to 23 Pa.C.S. §5325. (20)____________________________

______________________________________________________________________________

_____________________________________________________________________________.

(c) If the plaintiff is a person seeking physical and/or legal custody pursuant to

23 Pa.C.S. §5324(2) as a person who stands in loco parentis to the child, you must plead facts

establishing standing. (21)______________________________________________________

____________________________________________________________________________

____________________________________________________________________________.

19. I have attached the Criminal Record/Abuse History Verification form required

pursuant to Pa.R.C.P. No. 1915.3-2.

Wherefore, the Plaintiff respectfully requests this Court to grant him/her (Shared Legal

Custody) (Sole Legal Custody) (Partial Physical Custody) (Primary Physical Custody) (Shared

Physical Custody) (Sole Physical Custody) (Supervised Physical Custody) of the child(ren).

Respectfully submitted:

(22)______________________________________________ Plaintiff, Pro – Se


(1) , : Plaintiff : : : vs. : CIVIL ACTION NO. : (2) , : Defendant : ______________________________________________________________________________

CRIMINAL RECORD / ABUSE HISTORY VERIFICATION

I, (3) ________________________________, hereby swear or affirm, subject to

penalties of law including 18 Pa. C.S. §4904 relating to unsworn falsification to authorities that:

1. (4) Unless indicated by my checking the box next to a crime below, neither I nor any

other member of my household have been convicted or pled guilty or pled no contest or was

adjudicated delinquent where the record is publicly available pursuant to the Juvenile Act, 42

Pa.C.S. §6307 to any of the following crimes in Pennsylvania or a substantially equivalent crime

in any other jurisdiction, including pending charges: (5)

Check Crime Self Other Date of Sentence all that Household conviction, apply Member guilty plea, no contest plea or pending charges ( ) 18 Pa.C.S. Ch.25 ( ) ( ) ______________ ______

(relating to criminal homicide) ( ) 18 Pa.C.S.§2702 ( ) ( ) ______________ ______

(relating to aggravated assault)

( ) 18 Pa.C.S.§2706 ( ) ( ) ______________ ______ (relating to terroristic

threats) ( ) 18 Pa.C.S.§2709.1 ( ) ( ) ______________ ______

(relating to stalking) ( ) 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.§2910 ( ) ( ) ______________ ______

(relating to luring a child into a motor

vehicle or structure) ( ) 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)

( ) 18 Pa.C.S.§5902(b) ( ) ( ) ______________ ______

(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)

( ) 18 Pa.C.S.§6114 ( ) ( ) ______________ ______

(relating to contempt for violation of protection order or agreement)

( ) Driving under the ( ) ( ) ______________ ______

influence of drugs or alcohol ( ) Manufacturing, sale, ( ) ( ) ______________ ______

Delivery, holding Offering for sale or possession of any controlled substance or other drug or device

2. Unless indicated by my checking the box next to an item below, neither I nor any other member of my household have a history of violent or abusive conduct including the following: (6) Check Self Other Date all that Household apply Member ( ) A finding of abuse by a Children & ( ) ( ) ________ Youth Agency or similar agency in Pennsylvania or similar statute in another jurisdiction ( ) Abusive conduct as defined under the ( ) ( ) ________ Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction

( ) Other: __________________________ ( ) ( ) ________

3. Please list any evaluation, counseling or other treatment received following conviction or finding of abuse: _______________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________.

4. If any conviction above applies to 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/abuse history, please explain: _________________________________________ ___________________________________________________________________________________________________________________________________________________________. (7) 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. ___________________________ Signature ____________________________ Printed Name


_____________________________________________________________________________ (1) _____________________________________, : Plaintiff : : : VS. : CIVIL ACTION NO. : : (2) _____________________________________, : Defendant ______________________________________________________________________________ VERIFICATION I, (3) _______________________________, do hereby state, subject to the penalties of

18 Pa. C. S. Section 4904 relating to unsworn falsification to authorities, that the facts set forth in

the forgoing Complaint For Custody are true and correct to the best of my knowledge,

information, and belief.

______________________________ (4) __________________________________ DATE PLAINTIFF, PRO - SE

IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA CIVIL ACTION - LAW ______________________________________________________________________________

(1) ________________________________, : Plaintiff : : vs. : CIVIL ACTION NO. : (2) _______________________________, : Defendant : ORDER AND NOTICE TO: (3) __________________________________ A complaint has been filed in the Court of Common Pleas of Mercer County concerning

(Shared Legal Custody) (Sole Legal Custody) (Partial Physical Custody) (Primary Physical

Custody) (Shared Physical Custody) (Sole Physical Custody) (Supervised Physical Custody) of

the following child/children: (4)___________________________________________________

___________________________________________________________________________.

The Court has learned you may have a legal interest in custody of the child/children

named.

A Conference will be scheduled by the Hearing Master.

If you wish to protect any legal interest you may have, or wish to present evidence to the

Court on those matters, you should appear at the place and time and on the date scheduled.

If you wish to claim the right of custody, you may file a counterclaim.

If you fail to appear as provided by this Order, an order for custody may be entered

against you or the Court may issue a warrant for your arrest.

You must file with the court a verification regarding any criminal record or abuse history

regarding you and anyone living in your household on or before the initial in-person contact with

the court (including, but not limited to, a conference with a conference officer or judge or

conciliation) but not later than 30 days after the service of the complaint or petition.

(5) No party may make a change in the residence of any child which significantly impairs

the ability of the other party to exercise custodial rights without first complying with all of the

applicable provisions of 23 Pa.C.S. §5337 and Pa.R.C.P. No. 1915.17 regarding relocation.

YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU

DO NOT HAVE OR KNOW A LAWYER, THEN YOU SHOULD GO TO OR

TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN

GET LEGAL HELP:

MERCER COUNTY LAWYERS’ REFERRAL SERVICE C/O MERCER COUNTY BAR ASSOCIATION P.O. BOX 1302

HERMITAGE, PA 16148 Telephone: (724) 342-3111 AMERICANS WITH DISABILITIES ACT OF 1990 The Court of Common Pleas of Mercer County is required by law to comply with the Americans with Disabilities Act of 1990. For information about accessible facilities and reasonable accommodations available to disabled individuals having business before the court, please contact our office. All arrangements must be made at least 72 hours prior to any hearing or business before the court. You must attend the scheduled conference or hearing.


______________________________________________________________________________ (1) _____________________________________, : Plaintiff : : vs. : CIVIL ACTION NO. : (2) ____________________________________, : Defendant : ______________________________________________________________________________ ORDER APPOINTING MASTER IN ALL DOMESTIC RELATIONS ACTIONS EXCEPT PROTECTION FROM ABUSE

AND NOW, on this day of , 20____, ,

Esquire, is hereby appointed Master with respect to the following claims:

( ) In all claims involving martial property

( ) Enforcement of marital agreements

( ) Alimony and modification or termination thereof

( ) Counsel fees and costs

( ) Fault Divorces

( ) Contested Divorces and Annulments

(X) Preliminary Conferences only in custody cases

( ) Bifurcation hearings

A conference shall be held in all matters except Protection from Abuse.

A Hearing ( ) Conference (X) shall be conducted in the Master's Hearing Room,

Domestic Relations Office, North Courthouse Annex, Mercer, PA at a time and date to be

established by the Master.

2

If a Hearing is to be held, the parties shall be prepared to produce all of their evidence at

that time.

The Master shall make a report to this Court with a proposed Order, a copy of which shall

be furnished to the parties through their attorneys, or if no attorney by regular mail to the last

known address of the party. The Master's report shall contain a notice to the parties that within

ten days of the date of the report of the Master, any party may file exceptions to the report or any

part thereof to rulings on objections to evidence, to statements or findings of fact, conclusions of

law or to other matters occurring during the hearing. Notice shall also inform the parties that

matters not covered by exceptions are deemed waived unless, prior to entry of a final Order,

leave is granted to file exceptions raising these matters. If exceptions are filed, any other party

may file exceptions within ten days of the date of service of the original exceptions.

The Notice shall also state that if no exceptions are filed within the ten-day period, the

Court shall review the report and if approved, the Court will enter a final Order.

You are advised of your right to be represented by counsel throughout these proceedings.

BY THE COURT: _________________________________, J.


(1) _____________________________________, : Plaintiff : : vs. : CIVIL ACTION NO. : (2) _____________________________________, : Defendant : CERTIFICATE OF SERVICE I, (3) ___________________________, hereby certify that I am this day serving a true

and correct copy of the foregoing pleading upon the following individual(s) in the manner

described below:

Service by United States Mail, Certified, Return Receipt Requested, addressed as

follows:

(4) ____________________________________________

____________________________________________

____________________________________________

Respectfully submitted: By: (5) ___________________________________ Plaintiff, Pro - Se (6) ___________________________________

___________________________________

___________________________________

DATE: _______________________


, : Plaintiff : : : vs. : CIVIL ACTION NO. : , : Defendant : ______________________________________________________________________________


(1) I, ________________________________, hereby swear or affirm, subject to

penalties of law including 18 Pa. C.S. §4904 relating to unsworn falsification to authorities that:

6. Unless indicated by my checking the box next to a crime below, neither I nor any other

member of my household have been convicted or pled guilty or pled no contest or was



in any other jurisdiction, including pending charges:



(relating to aggravated assault) ( ) 18 Pa.C.S.§2706 ( ) ( ) ______________ ______

(relating to terroristic threats)

( ) 18 Pa.C.S.§2709.1 ( ) ( ) ______________ ______



( ) 18 Pa.C.S.§2902 ( ) ( ) ______________ ______










(relating to indecent assault) ( ) 18 Pa.C.S.§3127 ( ) ( ) ______________ ______

(relating to indecent exposure)

( ) 18 Pa.C.S.§3129 ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§3130 ( ) ( ) ______________ ______



( ) 18 Pa.C.S.§4302 ( ) ( ) ______________ ______



( ) 18 Pa.C.S.§4304 ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§4305 ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§5902(b) ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§5903(c) ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§6301 ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§6312 ( ) ( ) ______________ ______

(relating to sexual abuse of children)

( ) 18 Pa.C.S.§6318 ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§6320 ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§6114 ( ) ( ) ______________ ______





7. Unless indicated by my checking the box next to an item below, neither I nor any other member of my household have a history of violent or abusive conduct including the following: Check Self Other Date all that Household apply Member ( ) A finding of abuse by a Children & ( ) ( ) ________ Youth Agency or similar agency in Pennsylvania or similar statute in another jurisdiction ( ) Abusive conduct as defined under the ( ) ( ) ________ Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction ( ) Other: __________________________ ( ) ( ) ________

8. Please list any evaluation, counseling or other treatment received following conviction or

finding of abuse: _______________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________.


10. If you are aware that the other party or members of the other party’s household has or have a criminal/abuse history, please explain: _________________________________________ ___________________________________________________________________________________________________________________________________________________________. 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. ___________________________ Defendant Signature ____________________________ Printed Name

BLANK FORMS TO FOLLOW


, : Plaintiff : : : vs. : CIVIL ACTION NO. : , : Defendant : ______________________________________________________________________________ COMPLAINT FOR CUSTODY AND NOW, comes the Plaintiff, ____________________________, pro-se, and

respectfully represents as follows:

1. The Plaintiff is ________________________________, residing at

___________________________________________________________________________.

2. The Defendant is _________________________________, residing at

_____________________________________________________________________.

3. The Plaintiff seeks (Shared Legal Custody) (Sole Legal Custody) (Partial Physical

Custody) (Primary Physical Custody) (Shared Physical Custody) (Sole Physical Custody)

(Supervised Physical Custody) of the following child(ren):

Name Present Residence Date of Birth

____________________ _____________________ _______________

____________________ _____________________ _______________

____________________ _____________________ _______________

____________________ _____________________ _______________

4. The child(ren) (was/was not) (were/were not) born out of wedlock.

5. The child(ren)(is/are) presently in the custody of _________________________

who resides at ________________________________________________________________ .

6. During the past five years, the child(ren) (has/have) resided with the following

persons and at the following addresses:

Persons Addresses Dates

________________________ ______________________ ___________________

________________________ ______________________ ___________________

________________________ ______________________ ___________________

________________________ ______________________ ___________________

________________________ ______________________ ___________________

7. The mother of the child(ren) is ________________________, currently residing

at _________________________________________. She is (married) (divorced) (single).

8. The father of the child(ren) is _____________________, currently residing

at _________________________________________. He is (married) (divorced) (single).

9. The relationship of the Plaintiff to the child (ren) is that of __________________.

10. The Plaintiff currently resides with the following persons:

Name Relationship

_______________________________ ____________________________

_______________________________ ____________________________

_______________________________ ____________________________

11. The relationship of the Defendant to the child(ren) is that of

____________________.

12. The Defendant currently resides with the following persons:

Name Relationship

_________________________________ ________________________

_________________________________ ________________________

_________________________________ ________________________

13. The Plaintiff (has) (has not) participated as a party or witness, or in another capacity, in

other litigation concerning the custody of the child(ren) in this or another court. The court, term

and number, and its relationship to this action is: ______________________________________

_______________________________________________________________.

14. The Plaintiff (has) (has no) information of a custody proceeding concerning the

child(ren) pending in a court of this Commonwealth. The court, term and number, and its

relationship to this action is: ______________________________________________________

_______________________________________________________________.

15. The Plaintiff (knows) (does not know) of a person not a party to the proceedings

who has physical custody of the child(ren) or claims to have custodial rights with respect to the

child(ren). The name and address of such person is: ___________________________________

_____________________________________________________________ .

16. The best interest and permanent welfare of the child(ren) ___________________

_________________________________ will be served by granting the relief requested because

______________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________.

17. Each parent whose parental rights to the child(ren) have not been terminated and

the person who has physical custody of the child(ren) have been named as parties to this action.

All other persons, named below, who are known to have or claim a right to custody of the child

will be given notice of the pendency of this action and the right to intervene:

Name Address Basis of Claim

______________________________________________________________________________ ______________________________________________________________________________

18. (a) If the plaintiff is a grandparent who is not in loco parentis to the child and is

seeking physical and/or legal custody pursuant to 23 Pa.C.S. §5323, you must plead facts

establishing standing pursuant to 23 Pa.C.S §5324(3). __________________________________

______________________________________________________________________________

_____________________________________________________________________________.

(b) If the plaintiff is a grandparent or great-grandparent who is seeking partial

physical custody or supervised physical custody pursuant to 23 Pa.C.S. §5325, you must plead

facts establishing standing pursuant to 23 Pa.C.S. §5325. ________________________________

______________________________________________________________________________

_____________________________________________________________________________.

(c) If the plaintiff is a person seeking physical and/or legal custody pursuant to

23 Pa.C.S. §5324(2) as a person who stands in loco parentis to the child, you must plead facts

establishing standing.___________________________________________________________

____________________________________________________________________________

____________________________________________________________________________.

19. I have attached the Criminal Record/Abuse History Verification form required

pursuant to Pa.R.C.P. No. 1915.3-2.

Wherefore, the Plaintiff respectfully requests this Court to grant him/her (Shared Legal

Custody) (Sole Legal Custody) (Partial Physical Custody) (Primary Physical Custody) (Shared

Physical Custody) (Sole Physical Custody) (Supervised Physical Custody) of the child(ren).

Respectfully submitted:

______________________________________________ Plaintiff, Pro - Se




I, ________________________________, hereby swear or affirm, subject to penalties of

law including 18 Pa. C.S. §4904 relating to unsworn falsification to authorities that:










threats) ( ) 18 Pa.C.S.§2709.1 ( ) ( ) ______________ ______



( ) 18 Pa.C.S.§2902 ( ) ( ) ______________ ______












( ) 18 Pa.C.S.§3129 ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§3130 ( ) ( ) ______________ ______



( ) 18 Pa.C.S.§4302 ( ) ( ) ______________ ______



( ) 18 Pa.C.S.§4304 ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§4305 ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§5902(b) ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§5903(c) ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§6301 ( ) ( ) ______________ ______



( ) 18 Pa.C.S.§6318 ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§6320 ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§6114 ( ) ( ) ______________ ______




delivery, holding offering for sale or possession of any controlled substance or other drug or device

12. Unless indicated by my checking the box next to an item below, neither I nor any other member of my household have a history of violent or abusive conduct including the following: Check Self Other Date all that Household apply Member ( ) A finding of abuse by a Children & ( ) ( ) ________ Youth Agency or similar agency in Pennsylvania or similar statute in another jurisdiction ( ) Abusive conduct as defined under the ( ) ( ) ________ Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction

( ) Other: __________________________ ( ) ( ) ________



15. If you are aware that the other party or members of the other party’s household has or have a criminal/abuse history, please explain: _________________________________________ ___________________________________________________________________________________________________________________________________________________________. 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. ___________________________ Signature ____________________________ Printed Name

IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA CIVIL ACTION - LAW _____________________________________________________________________________ _______________________________________, : Plaintiff : : : vs. : CIVIL ACTION NO. : : _______________________________________, : Defendant ______________________________________________________________________________ VERIFICATION I, _______________________________, do hereby state, subject to the penalties of 18

Pa. C. S. Section 4904 relating to unsworn falsification to authorities, that the facts set forth in

the forgoing Complaint For Custody are true and correct to the best of my knowledge,

information, and belief.

____________________________ ____________________________________ DATE PLAINTIFF, PRO - SE


__________________________________, : Plaintiff : : vs. : CIVIL ACTION NO. : __________________________________, : Defendant :

ORDER AND NOTICE TO: __________________________________ A complaint has been filed in the Court of Common Pleas of Mercer County concerning

(Shared Legal Custody) (Sole Legal Custody) (Partial Physical Custody) (Primary Physical

Custody) (Shared Physical Custody) (Sole Physical Custody) (Supervised Physical Custody) of

the following child/children: ___________________________________________________

___________________________________________________________________________.

The Court has learned you may have a legal interest in custody of the child/children

named.

A Conference will be scheduled by the Hearing Master.

If you wish to protect any legal interest you may have, or wish to present evidence to the

Court on those matters, you should appear at the place and time and on the date scheduled.

If you wish to claim a right of custody, you may file a counterclaim.

If you fail to appear as provided by this Order, an order for custody may be entered

against you or the Court may issue a warrant for your arrest.

You must file with the Court a verification regarding any criminal record or abuse history

regarding you and anyone living in your household on or before the initial in-person contact with

the court (including, but not limited to, a conference with a conference officer or judge or

conciliation) but not later than 30 days after the service of the complaint or petition.

No party may make a change in the residence of any child which significantly impairs the

ability of the other party to exercise custodial rights without first complying with all of the

applicable provisions of 23 Pa.C.S. §5337 and Pa.R.C.P. No. 1915.17 regarding relocation.

YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU

DO NOT HAVE OR KNOW A LAWYER, THEN YOU SHOULD GO TO OR

TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN

GET LEGAL HELP:

MERCER COUNTY LAWYERS’ REFERRAL SERVICE C/O MERCER COUNTY BAR ASSOCIATION P.O. BOX 1302

HERMITAGE, PA 16148 Telephone: (724) 342-3111 AMERICANS WITH DISABILITIES ACT OF 1990 The Court of Common Pleas of Mercer County is required by law to comply with the Americans with Disabilities Act of 1990. For information about accessible facilities and reasonable accommodations available to disabled individuals having business before the court, please contact our office. All arrangements must be made at least 72 hours prior to any hearing or business before the court. You must attend the scheduled conference or hearing. BY THE COURT: ,J. DATE: ________________________


, : Plaintiff : : : vs. : CIVIL ACTION NO. : , : Defendant : ______________________________________________________________________________ ORDER APPOINTING MASTER IN ALL DOMESTIC RELATIONS ACTIONS EXCEPT PROTECTION FROM ABUSE

AND NOW, on this day of , 20___, ,

is hereby appointed Master with respect to the following claims:

( ) In all claims involving martial property

( ) Enforcement of marital agreements

( ) Alimony and modification or termination thereof

( ) Counsel fees and costs

( ) Fault Divorces

( ) Contested Divorces and Annulments

(X) Preliminary Conferences only in custody cases

( ) Bifurcation hearings

A conference shall be held in all matters except Protection from Abuse.

A Hearing ( ) Conference (X) shall be conducted in the Master's Hearing Room,

Domestic Relations Office, North Courthouse Annex, Mercer, PA at a time and date to be

established by the Master.

If a Hearing is to be held, the parties shall be prepared to produce all of their evidence at

that time.

The Master shall make a report to this Court with a proposed Order, a copy of which shall

be furnished to the parties through their attorneys, or if no attorney by regular mail to the last

known address of the party. The Master's report shall contain a notice to the parties that within

ten days of the date of the report of the Master, any party may file exceptions to the report or any

part thereof to rulings on objections to evidence, to statements or findings of fact, conclusions of

law or to other matters occurring during the hearing. Notice shall also inform the parties that

matters not covered by exceptions are deemed waived unless, prior to entry of a final Order,

leave is granted to file exceptions raising these matters. If exceptions are filed, any other party

may file exceptions within ten days of the date of service of the original exceptions.

The Notice shall also state that if no exceptions are filed within the ten-day period, the

Court shall review the report and if approved, the Court will enter a final Order.

You are advised of your right to be represented by counsel throughout these proceedings.

BY THE COURT: _________________________________, J.


, : Plaintiff : : : vs. : CIVIL ACTION NO. : , : Defendant : ______________________________________________________________________________ CERTIFICATE OF SERVICE I, ___________________________, hereby certify that I am this day serving a true and

correct copy of the foregoing pleading upon the following individual(s) in the manner described

below:

Service by United States Mail, Certified, Return Receipt Requested, addressed as

follows:

____________________________________________

____________________________________________

____________________________________________

Respectfully submitted: By: ___________________________________ Plaintiff, Pro - Se ___________________________________

___________________________________

___________________________________

DATE: _______________________




I, ________________________________, hereby swear or affirm, subject to penalties of

law including 18 Pa. C.S. §4904 relating to unsworn falsification to authorities that:










threats) ( ) 18 Pa.C.S.§2709.1 ( ) ( ) ______________ ______



( ) 18 Pa.C.S.§2902 ( ) ( ) ______________ ______












( ) 18 Pa.C.S.§3129 ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§3130 ( ) ( ) ______________ ______



( ) 18 Pa.C.S.§4302 ( ) ( ) ______________ ______



( ) 18 Pa.C.S.§4304 ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§4305 ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§5902(b) ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§5903(c) ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§6301 ( ) ( ) ______________ ______



( ) 18 Pa.C.S.§6318 ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§6320 ( ) ( ) ______________ ______


( ) 18 Pa.C.S.§6114 ( ) ( ) ______________ ______





2. Unless indicated by my checking the box next to an item below, neither I nor any other member of my household have a history of violent or abusive conduct including the following: Check Self Other Date all that Household apply Member ( ) A finding of abuse by a Children & ( ) ( ) ________ Youth Agency or similar agency in Pennsylvania or similar statute in another jurisdiction ( ) Abusive conduct as defined under the ( ) ( ) ________ Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction

( ) Other: __________________________ ( ) ( ) ________



5. If you are aware that the other party or members of the other party’s household has or have a criminal/abuse history, please explain: _________________________________________ ___________________________________________________________________________________________________________________________________________________________. 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. ___________________________ Defendant Signature ____________________________ Printed Name

PRO - SE CUSTODY PACKET · PRO - SE CUSTODY PACKET Instructions For Completing The Custody Forms...

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