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**Rule 1959. Forms for Use in Protection of Victims of Sexual Violence or**  **Intimidation A ctions. Notice and Hearing. Petition. Temporary**  **Protection Order. Final Protection Order.**  * * * (b) The petition in an action filed pursuant to the Act shall be identical in content to the following form: (Caption)

**PETITION FOR PROTECTION OF VICTIM**  **S OF** 

**SEXUA L VIOLENCE**  **SEXUA L VIOLENCE**  **AG AI**  **NST A**  **MINOR CHIL D**  **INTIMIDA TION**  1. Plaintiff:

_____________________________________________________________________ First Middle Last Name Plaintiff’s Address : ______________________________________________________ Plaintiff’s address is confidential pursuant to 42 Pa.C.S. § 62A11 . Plaintiff’s Date of Birth : _______________________________________________ I am filing this petition on behalf of myself or another person. If you checked “myself,” please answer all questions referring to yourself as “ P laintiff.” If you checked “another pe rson,” please answer all questions referring to that person as “Plaintiff,” and provide your name and address below. Name: __________________________________________________________ Address: _________________________________________________________ If you checked “another person,” indicate your relationship to the plaintiff:

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2. Defendant :

________________________________ First Middle Last Name Defendant’s Address :

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________________________________ **DEFENDANT IDENTIFIERS**  DOB HEIGHT SEX WE IGHT RACE EYES HAIR SSN DRIVERS LICENSE # EXP DATE STATE 3 . Name (s ) of other designated person (s ) under 4 2 Pa.C.S. § 62A07(b)(1):

____________________________________________________________________ 4 . Is there a relationship between Plaintiff and Defendant? ________. If yes, what is the relationship?

_____________________________________________________________________ 5 . Have Plaintiff and Defendant been involved in any other legal proceedings ? If so, state when and where the case was filed and the court docket number, if known:

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_____________________________________________________________________ 6 . Has Defendant been involved in any criminal proceedings ?

______________________________________________________ ________________ If you answered Yes, is Defendant currently on probation or parole ?

_____________________________________________________________________ 7 . (a) The facts of the most recent incident of sexual violence are as follows: Approximate Date: ____________________________________________________ Approximate Time: ____________________________________________________ Place: ________________________________________________________________ Describe in detail what happened, including any physical or sexual abuse, threats, injury, incidents of stalking, medical treatment sought, and/or calls to law enforcement (attach additional sheets of paper if necessary):

______________________________________________________________________
_____________

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(b) The facts of the most recent incident of intimidation are as follows: Approximate Date: ________________________________ ______________

__ ______ Approximate Time: ________________________________________ __ ____________ Place: ________________________________________________________________ Describe in detail what happened, including medical treatment sought, and/or calls to law enforcement (attach additional sheets of paper if necessary):

______________________________________________________________________
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______________________________________________________________________ 8 . If Defendant has committed prior acts of sexual violence or intimidation against Plaintiff, describe these prior incidents, and indicate approximately when such acts occurred (atta ch additional sheets of paper if necessary):

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______________________________________________________________________ 9 . Identify the sheriff, police department , or other law enforcement agency in the area in which Plaintiff lives that should be provided with a copy of the protection order:

_________________________________________________________________ __ ___ 10 . Is **[ there**  **an ]**  **Plaintiff in** immediate and present danger **[ for further acts of**  **sexual violence or intimidation ]**  from Defendant **[ against Plaintiff**  **]** ? If so, please describe : ______________________________________________________________ FOR THE REASONS SET FORTH ABOVE, I REQUEST THAT THE COURT ENTER A TEMPORARY ORDER AND , AFTER A HEARING, A FINAL ORDER THAT WO ULD INCLUDE ALL OF TH E FOLLOW ING RELIEF (CHECK ALL FORMS OF RELIEF REQUESTED): A. Restrain Defendant from having any contact with the victim, inclu ding, but not limited to, entering the victim’s residence, place of employment, business , or school. B. Prohibit indirect contact through third parties. C. Prohibit direct or indirect contact with other designated persons.4

D . Order Defendant to pay the fees of this action. E. Order the following additional relief, not listed above:

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______________________________________________ ________________________ F. Grant such other relief as the court deems appropriate , including, but not limited to, issuing an order under 42 Pa.C.S. § 62A11(b) related to the non-disclosure of the victim's address, telephone number, whereabouts or othe r demographic information . G. Order the police, sheriff or other law enforcement agency to serve the Defendant with a copy of this petition, any order issued, and the order for the hearing. Plaintiff will inform the designated authority of any addresses, other than Defendant’s residence, where Defendant can be served. **VERIFICA TION**  I verify that the statements made in this petition are true and correct to the best of my knowledge. 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

_____________________________________________________________________ Date * * *