Pennsylvania Code › Title 231 - RULES OF CIVIL PROCEDURE › Part I - GENERAL › Chapter 1900 - ACTIONS PURSUANT TO THE PROTECTION FROM ABUSE ACT › Rule 1905 - Forms for Use in PFA Actions. Notice and Hearing. Petition. Temporary Protection Order. Final Protection Order

Current through Register Vol. 54, No. 28, July 13, 2024
(a) The Notice of Hearing and Order required
				by Rule 1901.3 shall be substantially in
				the following form:
(Caption)
NOTICE OF HEARING AND ORDER
YOU HAVE BEEN SUED IN COURT. If you wish to defend against
				  the claims set forth in the following papers, you must appear at the hearing
				  scheduled herein. If you fail to do so, the case may proceed against you and a
				  FINAL order may be entered against you granting the relief requested in the
				  petition. In particular, you may be evicted from your residence, prohibited
				  from possessing any firearm, other weapon, ammunition, or any firearm license,
				  and lose other important rights, including custody of your children. A
				  protection order granted by a court may be considered in subsequent proceedings
				  under Title 23 (Domestic Relations) of the Pennsylvania Consolidated Statutes,
				  including child custody proceedings under Chapter 53 (relating to custody) and
				  Child Protective Services Law proceedings under Chapter 63 (related to juvenile
				  matters).
A hearing on the matter is scheduled for the ___ day of ___ ,
				  20 ___ , at ___ .m., in Courtoom ___ at ___ Courthouse, ___ ,
				  Pennsylvania.
If an order of protection has been entered, you MUST obey the
				  order until it is modified or terminated by the court after notice and hearing.
				  If you disobey this order, the police or sheriff may arrest you. Violation of
				  this order may subject you to a charge of indirect criminal contempt which is
				  punishable by a fine of up to $1,000 and/or up to six months in jail under
				  23 Pa.C.S.A. §
											6114.
				  Violation may also subject you to prosecution and criminal penalties under the
				  Pennsylvania Crimes Code. Under federal law,
				  18 U.S.C. §
											2265, this order is enforceable anywhere in
				  the United States, tribal lands, U. S. Territories and the Commonwealth of
				  Puerto Rico. If you travel outside of the state and intentionally violate this
				  order, you may be subject to federal criminal proceedings under the Violence
				  Against Women Act, 18 U.S.C.
				  §§
											2261-2262.
If this order directs you to relinquish any firearm, other
				  weapon, ammunition or any firearm license to the sheriff, you may do so upon
				  service of this order. As an alternative, you may relinquish any firearm, other
				  weapon, or ammunition listed herein to a third party provided you and the third
				  party first comply with all requirements to obtain a safekeeping permit.
				  23 Pa.C.S.A §
											6108.3. You must relinquish any firearm,
				  other weapon, ammunition or any firearm license listed in the order no later
				  than 24 hours after service of the order. If, due to their current location,
				  firearms, other weapons or ammunition cannot reasonably be retrieved within the
				  time for relinquishment, you must provide an affidavit to the sheriff listing
				  the firearms, other weapons or ammunition and their current location no later
				  than 24 hours after service of the order. Failure to timely relinquish any
				  firearm, other weapon, ammunition or any firearm license shall result in a
				  violation of this order and may result in criminal conviction under the Uniform
				  Firearms Act,
				  18 Pa.C.S.A. §
											6105.
NOTICE: Even if this order does not direct you to relinquish
				  firearms, you may be subject to federal firearms prohibitions and federal
				  criminal penalties under 18
				  U.S.C. §
											922(g)(8) or
				  state firearms prohibitions and state criminal penalties under 18 Pa.C.S.
				  § 6105.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. YOU HAVE
				  THE RIGHT TO HAVE A LAWYER REPRESENT YOU AT THE HEARING. THE COURT WILL NOT,
				  HOWEVER, APPOINT A LAWYER FOR YOU. IF YOU DO NOT HAVE A LAWYER, GO TO OR
				  TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH
				  INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS
				  OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY
				  OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. IF YOU
				  CANNOT FIND A LAWYER, YOU MAY HAVE TO PROCEED WITHOUT ONE.
County Lawyer Referral Service
[insert Street Address]
[insert City, State, and ZIP]
[insert Phone Number]
(b) The petition in an action filed pursuant
				to the Act shall be substantially in the following form, but the first page
				(paragraphs 1 through 4), following the Notice of Hearing and Order, shall be
				exactly as set forth in this rule:
PETITION FOR PROTECTION FROM ABUSE
Click
				  to view image
5. Indicate
				the relationship between Plaintiff and Defendant.
CHECK ALL THAT APPLY:
[] spouse or former spouse of Defendant
[] parent of a child with Defendant
[] current or former sexual or intimate partner with
				  Defendant
[] child of Plaintiff
[] child of Defendant
[] family member related by blood (consanguinity) to
				  Defendant
[] family member related by marriage or affinity to
				  Defendant
[] sibling (person who shares parenthood) of Defendant
[] Check here if Defendant is 17 years old or
				  younger.
6. Have Plaintiff
				and Defendant been involved in any of the following court actions?
[] Divorce
[] Custody
[] Support
[] Protection From Abuse
If you checked any of the above, briefly indicate when and
				  where the case was filed and the court number, if known:
				  ______________________________________
______________________________________
______________________________________
7. Has Defendant been involved in any
				criminal court action? ____________
If you answered Yes, is Defendant currently on probation?
				  ____________
Has Defendant been determined to be a perpetrator in a
				  founded or indicated report under the Child Protective Services Law,
				  23 Pa.C.S. §§
												6301- 6386? ____________
If you answered Yes, what county's court or child protective
				  services agency issued the founded or indicated report?
				  ____________
8. Plaintiff
				and Defendant are the parents of the following minor child/ren:
Name(s)
Age(s)
who reside at (list
							 address unless confidential)
____________
___
_____________________
____________
___
_____________________
____________
___
_____________________
____________
___
_____________________
9. If
				Plaintiff and Defendant are parents of any minor child/ren together, is there
				an existing court order regarding their custody? _______
If you answered "Yes," describe the terms of the order (e.g.,
				  primary, shared, legal and/or physical custody):
___________________________________________
If you answered "Yes," in what county and state was the order
				  issued?
___________________________________________
If you are now seeking an order of child custody as part of
				  this petition, list the following information:
(a) Where has each child resided during the
				past five years?
Child's name
Person(s) child lived
							 with
Address, unless confidential
When
____________
____________
____________
___
____________
____________
____________
___
____________
____________
____________
___
____________
____________
____________
___
(b)
				List any other persons who are known to have or claim a right to custody of
				each child listed above.
Name
Address
Basis of Claim
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
10. The following other minor child/ren
				presently live with Plaintiff:
Name(s)
Age(s)
Plaintiff's
							 relationship to child/ren
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
____________
11.
				The facts of the most recent incident of abuse 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):
______________________________________
______________________________________
______________________________________
12. If Defendant has committed prior acts of
				abuse against Plaintiff or the minor child/ren, describe these prior incidents,
				including any threats, injuries, or incidents of stalking, and indicate
				approximately when such acts of abuse occurred (attach additional sheets of
				paper if necessary):
______________________________________
______________________________________
______________________________________
13.
(a) Has
				Defendant used or threatened to use any firearms or other weapons against
				Plaintiff or the minor child/ren? If so, please describe the use or threatened
				use below and list on Attachment A to Petition, which is incorporated by
				reference into this petition, any firearms, other weapons or ammunition
				Defendant used or threatened to use against Plaintiff and/or the minor
				children: ______________________________________
______________________________________
______________________________________
(b) Other than the firearms, other weapons or
				ammunition Defendant used or threatened to use against Petitioner or the minor
				child/ren, does Defendant, to the best of your knowledge or belief, own or
				possess any additional firearm, other weapon, ammunition or any firearm
				license?
(c) If the answer to (b)
				above is "yes," list any additional firearm, other weapon or ammunition owned
				by or in the possession of Defendant on Attachment A to Petition, which is
				incorporated by reference into this petition.
(d) Plaintiff (
check one
) []
				DOES [] DOES NOT request that the court order Defendant to relinquish firearms,
				other weapons or ammunition listed on Attachment A to Petition. If Plaintiff
				does seek relinquishment, identify on Attachement A to Petition the firearms,
				other weapons and ammunition Plaintiff requests the court to order Defendant to
				relinquish.
14. Identify
				the sheriff, police department or law enforcement agency in the area in which
				Plaintiff lives that should be provided with a copy of the protection order:
______________________________________
______________________________________
15. There is an immediate and present danger
				of further abuse from Defendant.
CHECK THE FOLLOWING BOXES ONLY IF THEY APPLY TO YOUR CASE AND
				  PROVIDE THE REQUESTED INFORMATION
[] Plaintiff is asking the court to evict and exclude
				  Defendant from the following residence:
				  ______________________________________
[] owned by (list owners, if known):
				  _____________________________________
[] rented by (list all names, if known):
				  ____________________________________
[] Defendant owes a duty of support to Plaintiff and/or the
				  minor child/ren: ______
[] Plaintiff has suffered out-of-pocket financial losses as
				  a result of the abuse described above. Those losses are:
				  ______________________________________
______________________________________
FOR THE REASONS SET FORTH ABOVE, I REQUEST THAT THE COURT
				  ENTER A TEMPORARY ORDER, and AFTER HEARING, A FINAL ORDER THAT WOULD DO THE
				  FOLLOWING (CHECK ALL FORMS OF RELIEF REQUESTED):
[] A. Restrain Defendant from abusing, threatening,
				  harassing, or stalking Plaintiff and/or the minor child/ren in any place where
				  Plaintiff and/or the child/ren may be found.
[] B. Evict/exclude Defendant from Plaintiff's residence and
				  prohibit Defendant from attempting to enter any temporary or permanent
				  residence of Plaintiff.
[] C. Require Defendant to provide Plaintiff and/or the
				  minor child/ren with other suitable housing.
[] D. Award Plaintiff temporary custody of the minor
				  child/ren and place the following restrictions on contact between Defendant and
				  the child/ren: ______________________________________
______________________________________
[] E. Prohibit Defendant from having any contact with
				  Plaintiff and/or the minor child/ren, either in person, by telephone, or in
				  writing, personally or through third persons, including but not limited to any
				  contact at Plaintiff's school, business, or place of employment, except as the
				  court may find necessary with respect to partial custody and/or visitation with
				  the minor child/ren.
[] F. Prohibit Defendant from having any contact with
				  Plaintiff's relatives and Plaintiff's children listed in this petition, except
				  as the court may find necessary with respect to partial custody and/or
				  visitation with the minor child/ren. The following persons are Plaintiff's
				  relatives or family and household members that Plaintiff believes require
				  protection from stalking and harassment by Defendant.
Name
Address (optional)
Relationship
							 to Planitiff
_____________________________________
_____________________________________
_____________________________________
[] G. Order Defendant to temporarily relinquish the
				  firearms, other weapons, or ammunition listed on Attachment A to Petition,
				  under Defendant's control, or in Defendant's possession, or any firearm license
				  to the sheriff or the appropriate law enforcement agency.
[] H. Prohibit Defendant from acquiring or possessing
				  firearms for the duration of the order.
[] I. Order Defendant to pay temporary support for Plaintiff
				  or the minor child/ren, including medical support and payment of the rent or
				  mortgage on the residence.
[] J. Direct Defendant to pay Plaintiff for the reasonable
				  financial losses suffered as the result of the abuse, to be determined at the
				  hearing.
[] K. Order Defendant to pay the costs of this action,
				  including filing and service fees.
[] L. Order Defendant to pay Plaintiff's reasonable
				  attorney's fees.
[] M. Order the following additional relief, not listed
				  above:
______________________________________
______________________________________
______________________________________
[] N. Grant such other relief as Plaintiff requests or the
				  court deems appropriate.
[] O. Order the police, sheriff, or other law enforcement
				  agency to serve Defendant with a copy of this petition, any order issued, and
				  the order for hearing. Plaintiff will inform the designated authority of any
				  addresses, other than Defendant's residence, where Defendant can be
				  served.
[] P. Direct the Pennsylvania State Police, the municipal
				  police, or the sheriff to accompany Plaintiff to his or her residence to
				  retrieve personal belongings or accompany Plaintiff while the petition or order
				  is served on Defendant, if Plaintiff has reason to believe his or her safety is
				  at risk.
VERIFICATION
I verify that I am the petitioner as designated in the
				  present action and that the facts and statements contained in the above
				  petition are true and correct to the best of my knowledge. I understand that
				  any false statements are made subject to the penalties of
				  18 Pa.C.S.A. §
												4904,
				  relating to unsworn falsification to authorities.
______________________________________
Signature
______________________________________
Date
(Caption)
ATTACHMENT A TO PETITIONFIREARMS, OTHER WEAPONS AND
				  AMMUNITION INVENTORY
I, ____________ , Plaintiff in this Protection From Abuse
				  Action, hereby
(a) state that Defendant
				used or threatened to use the following firearms, other weapons and ammunition
				against Plaintiff and/or the minor child/ren (include addresses or locations,
				if known, such as "front seat of blue truck," "gun cabinet," "bedroom closet,"
				etc.):
Firearm/Other Weapon/Ammunition
Location
1.
2.
3.
4.
5.
(b)
				state that Defendant, to the best of my knowledge or belief, owns or possesses
				the following firearms, other weapons or ammunition not set forth in (a) above
				(include addresses or locations, if known):
Firearm/Other Weapon/Ammunition
Location
1.
2.
3.
4.
5.
(c)
				request that the court order Defendant to relinquish the following firearms,
				other weapons and ammunition (include addresses or locations, if known):
Firearm/Other Weapon/Ammunition
Location
1.
2.
3.
4.
5.
[] All firearms, other weapons and ammunition owned or
				  possessed by Defendant. If more space is needed, more sheets may be attached to
				  this document.
Name ______________________________________
Date ______________________________________
Notice: This attachment will be withheld from public
				  inspection in accordance with
				  23 Pa.C.S.A. §
													6108(a)(7)(v).