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No, i/7 - ~ J- LI 8" (w.....1!. T~, ......
IN THE COURT OF COMMON PLEAS OF YORK COUNTY. PENNSYLVANIA
:! Q. At Iv Olf/5o NO /)7,CAI 6 g
'i ~Iaintlff '1 CJlA
I verS'JS PRO SE 5/J...s _ 5 ~ 9 ')
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Defendant
CIVIL ACTION LAW
PROTECTION FROM ABUSE
NOTICE TO DEFEND
" YOU HAVE BEEN SUED IN COURT, The Plaintiff is the person suing on behalf
of the abused person(s). Attached is a copy of the Petition which indicates the relief
; the Plaintiff is requesting, Also included In the Petition are Plaintiffs reasons for these
I requests,
i YO~~t c;gp,ear at the hearing on the -fl- day of -;/ ~J~"-.-
119il at 6JlA'.IP,M, in Court Room No, ~ of the Court of Common Pleas
, of York County, located at 28 East Market Street. York, PA
If you do not appear at the hearing at the time and place as set forth above, the
Order requested by Plaintiff may be granted in your absence, and you may lose money
or property fights or other rights important to you, and/or a bench warrant may be
issued directing the Sheriff to bring you into Court.
If a copy of a TEMPORARY ORDER is attached, you must obey it untillhe
hearing, If you do not obey it, the police can arrest you and you may be charged with
indirect Criminal Contempt.
I '. ro. .1, I ',~
YOU SHOULD TAKE THiS PAPER TO YOUR LAWYER 6LONCE YOU HAVE
A RIGHT TO HAVE AN ATIORNEY REPRESENT YOU AT THE HEARING. IF YOU
DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE
THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU MAY GET ~aGA~
HELP, (, ~- ,~-,,:
_..,. cj
c3.- "'1:.;:' (
))!Jof. t9C;J.n, LAVVYER REFERRAL SERVICE ;;:~ ~:':;j
<:,' :, ,,' ." " I . "I ~ tf the York County Bar ASSOCiation j':;' ~ :~:',~;
, ' '. "'i'i ' . "'"lIlt,1 137 East Market Street r'o :::: ~. '.J
I \ York, PA 17401 .; ;.;
1\, (717) 771-9361 ""-J,
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ONLY CI~l(i'Lf:';C--l
IN THE COURT OF COMMON PLEAS OF YORK COUNTY, PENNSYLVANIA
Coo, 0"1, ; NO. CJ7SL/,() 5L/.?:}-!-'!!~fi
Plaintiff .- ..,
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CIVIL ACTION LAW ~~:, :=. ,!,
PROTECTION FROM ABUSE f'" ~ "
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versus
PRO SE
E>{ ; Q(\ 0 {( i ~
Defendant
PETITION FOR PROTECTION FROM ABUSE
@() I live at_
Street Address
City
, Pennsylvania
Township County Zip Code
OR (~lIve In this County at an undisclosed address for my protection,
3. I am filing this Petition for temporary and final protection Orders pursuant to
the Protection From Abuse Act. 23 Pa,C,S.A. ~6101 et seq, I am seeking relief as
(guardian ad litem for a chlld(ren) whose name(s) Is
4. ( ) The abused person(s) resides at
Street Address
City
Pennsylvania with
Township
County
Zip Code
(Name and relationship to the abused person of adult co-resident).
OR ( ) The abused person(s) is living In this County at an undisclosed address
for his/her/their protection,
3"'(P old YOlK ~oo)dl Ntw C'umbulw Pit 1'=10%
,.
~
.(95, he person I am filing this Petition agalnlltls _CJ ( ; An 0 ( (i .5 ,
lh Defen ant who resides at-.C} /IS .C;o,.'U-. "Ft.n+ 5-1 :c:.-tuHn(\ ,
Street Address City ,
<)tm,*-b~llph:^ ,Pennsylvania ~
TONnshlp County Zip Code
6, T e Defendant's Social Security number Is J '1-4, (, :;l. y ;l,3G:>
efen ant's date of birth Is I I 'XLiI's .
Th
, The Defendant I~ ~ ~( . (state
relat n p to abused person(s): such as husband or fa er husband, sexuallintlmate
partner, house mate, child, son or daughter, etc.), '
8. The Defendant worns at
Name of Employer
located at
Pennsylvania.
9. ( ) The residence of the abused person(s) from which I am asking the Court
to exclude the Defendant Is owned (rented) in the name of
OR ( ) I cannot reveal the name(s) of the owner(s) or renter(s) of the residence
from which I am asking the Court to exclude the Defendant for the name(s) will disclose
the whereabouts of the abused person(s) which must be kept confidential for
her/his/their protection,
10, 1: e facts of the most recent Incident of abuse are as follows: (Please write
a brl f d criptlon of the incident Including shoves, kicks or blows inflicted, weapons
used, hreats made, instances of stalking, injuries sustained, medical .or hospital
treatment necessary, If any,)
Date lo/~11/9t-:J.
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.:b.1..L..:it.- J 11:il"~, rrr
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O~'~IOII$, 7h(rt
a,~ Location ij-... /:::,. i"'I",,,,d tII~
l::,. -rooK 0':1' hi~ 8U(\ :!fld
Time /D: otJ
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ovlltt hole.. /" oit.$,dt dool'
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QI\~ b~I/..-r hblt. In~,r:J1'.. Wall, 1~'6n-t dbel t.J~$
bl\Kt/\ ue ;1\ ~p(l.'1-. ',~...t ~l'C!a O(bvnd k~llcJjC!.
W"'lSkr Cjj W~ ~1l)YI~ W j'fh (jf:.s "j~-t(!J' ~ boy-fo&lJ:. -f'Olmrly.
;)1I~d '/-htm Qnd %rerleA 40 kill lIT:... .$/.itUJ ',;;,\y-f'lfIIJ <nd
P'j,~t. ,
([J up ~l'\d G>>,: ~J 'it o;t ~ (t\bm, ~ -b.1L.CIr" y~" ~
1.. \...1.. 'I
N'c- -&-nW Y bU ,
~' iThe Defendant has physlcally.abused me and/or the Incompetent adult
and/ mln r ehlldlen(ren) In the past. The following are some examples of past
abusl onduet: (Describe In brief some of the most recent and/or most serious
incidents of past physical abuse. State an approximate date for eaeh Incident.)
A l/qt:J. - A-flu ~I\ ~r~,)"",,rr I A ~ C"'+ ~U/"\
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B. rrr Jllmp:. <;It 6. w~^ 7r <r.b. Q~
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.a.....r.hJd ~nrl illt'-s '/:h'..s ~.~ -hi J/~d.J1
c.7r ,:'" :sf(',l;d ~ " ~.jpt'.CJ ; ':I II{ ..s '/let'
~b oVT" jUfl w~n r;-r ~l\cI b.. Mr
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PLEASE CIRCLE 112 - 16). IF APPLIES TO YOU
(12) The abused person(s) is In immediate danger of further abuse and a Court
orde~eeessary to protect the abused.
(1'~ I believe that service cannot be safely effected by an adult Individual other
tha~ enforcement officer.
G I ask for attorney fees and cost~ pursuant to the Protection From Abuse Act.
- 3 -
/'.
15, The abused (and or I) have suffered out-of-pocket losses as a result of
Defendant's abuse, '
. Qhe Defendant has used or t reatened to us~ the following weapons In his
abuse against the abused person(s): ' ,
WHEREFORE, Plaintiff requests that this Honorable Court award the following
relief:
A. Gra~TempOrary Order pursuant to the Protection from Abuse Act:
rdering the Defendant to stop abusing, harassing, threatening and
stalking the a ed (and the Plaintiff) and stop placing the abused (and the Plaintiff)
In fear of abuse in any place where she/he/they may be found,
( Evicting the Defendant from the residence located at
Street Address
Pennsylvania
Zip Code
City
Township
County
(OR a confidential address at which the abused Is now living) and a:1Y subsequent
residence In which the abused lives during the pendency of this Order, and granting
exclusive possession of the premises to the abused. OR If applicable, ordering the
Defendant to provide and pay for alternative suitable housing for the abused, approved
by Plaintiff, and g~antlng exclusive possession of the housing to the abused.)
;Qohlbltlng the Defendant from having any contact with the abused,
Including, bi~hnited to, restraining the Defendant from entering the place of
employment, business or school or recreation of the abused and from haraSSing the
abused orthe b sed's relatives. .
",. Granting temporary custody of the abused minor child(ren) to
(Name(s) of C stodian(s)
;1(~rdering the Defendant to relinquish the following weapons which he
has used or t~ned to use against the abused: ;;,11 -flre.iU'M..<;.
- 4 -
;1,_,il1,~"-"l-,
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e.'
Irectlng the
(Sheriff or other law enforcement agency)
to serve a copy of the Petition and Temporary Order upon Defendant without
prepayment of costs.
( ) Directing that the Petition and Order In this matter may be served
upon Defendant without the disclosure of the address of the abused and also directing
the police and all Court personnel not to reveal any residential address of the abused
to the Defendant, his counsel and any third party,
8, Schedule a hearing and at such hearing, enter a one-year Order which
Includes the aije In addition to the following:
) ranting temporary support for the abused 111 the maximum amount
allowed unde la . " .
( ) Ordering the Defendant to reimburse Plaintiffs and the abused's out-
of-pocket losse uffered as a result of the abuse.
rderlng the Defendant to pay all costs associated with the filing and
service of thl' aw suit and to pay Plaintiffs and the abused's attorney's fees.
D ectlng the Defendant to..h:il w... no (' onti0' ~: Yil '!J
, ..sucu.5s1Jly (lotr'\"l~ 4'" A Chul\<:.fl.
ul (Specify addltl nal rellefrequ~sted) llJ h '
brn{t..~ lI.u...",~J VI,)itort'M 1..1: T1'\ r;r.. [:).. c :/0,
ranting any other relief the Court deems appropriate.
'verify that the statements made In this Petition are true and correct to
the best of my knowledge, information and 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.
Dated: ~ / / ~ /9;
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c/o. ~ O/Vt0
Pial iff
REV 12/94
.5.
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ONLY CIRCLED
ITEMS APPLY
IN THE COURT OF COMMON PLEAS OF YORK COUNTY, PENNSYLV~IA::
_I __
CJJ~/~ ()((i~ NO, q7 ~ .C:-Lf.l2(!~-g:d: \"";'_
lalntlff ' . I J' 0 c ' , -" ,',
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PRO SE . C' ~ ;':.'"
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versus
~Il 0 (I~
Defendant
CIVIL ACTION LAW
PROTECTION FROM ABUSE
AND NOW, this 7
TEMPO;Z;;; L
day of 'Jt
,1~, upon
review of the Petition of Plaintiff, the Court enters the following Temporary Order:
rQhe Defendant shall refrain from abusing, harassing, threatening and stalking
the Pt,'nllff <,"d the m'n" &1" p',,'n9 h,,'h'mlthem 'n fe" of ,b"e in ,"y
place w e she/he/they may be found.
) Defendant Is enjoined and prohibited from IWlno at, f19!erlng, attemptl g
r or visiting the residence located at ,.' , . ,...2.~.~ _ . .~ ~
Street Address City
, Pennsylvania, and any
Township
County
Zip Code
subsequent residence In which Plaintiff resides during the pendency of this Order, and
Plalntlff.7jnted exclusive possession of the premises.
t!:Y Defendant is enjoined and prohibited form living at, entering, attempting
to enter or visiting the residence of Plaintiff located at a confidential address within this
County. Which address remains confidential to protect Plaintiff from the danger of
future abuse by Defendant, and any subsequent residence In which Plaintiff resides
- .. _...___________..___ _..n.__._ . _ . '.'m._.~...~_____.________.._._._ ___....__ ____.
o
, .
during the pendency of this Order, and Plaintiff Is granted exclusive possession of the
'he Defendant Is prohibited from having any contact with the Plaintiff,
Inclu , but not limited to, entering the place of employment, business or school of
the Plaintiff (and the mlnor~;Jen) and harassing the Plaintiff.
roThe Plalnurf Is awarded temporary custody of he rl)0or chlld(ren)
'U ~L . ' 't9 /9;
Name(s) of chlld(ren)
@he Defendant Is directed to mediately relinquish the following weapons
to the Sheriff of this County:
6. The Defendant
to provide the following additional relief:
@hlS Order shall be enforced b~ any law enforcement agency In a County
where a violation of this Order occurs.
8. Law enforcement officers, the staff of the County registry of Protection
Orders, and Court personnel shall not disclose the address of the domestic violence
program and any confidential address of Plaintiff to the Defendant, his counselor any
third party.
- 2.
._~..__._----_.~._--
o
. ,
@ copy of this Order shall be served on the police department(s) In the
Jurisdictions where Plaintiff resides and Is employed. This Order shall, likewise, be
served on the State Pollee. A copy of this Order shall be forthwith filed In the County
,
registry of Protectfon Orders. Caples shall also be provided 10 the Sheriff, the
Prothonotary, Plaintiffs counsel, and Plaintiff, The Sheriff or _
(Specify other adult Individual)
Is directed to serve and file the aforementfoned caples of this Order without prepayment
of costs. Said caples shall be certified,
!1io:lhlS Order shall remain In full force and effect until modified or terminated
by t~s~t.
.' ,rlIThe Defendant's Social S curl number Is.l 7Y'-fo). ''(,)31{ The date
of blrk.elthe Defendant is .
~A hearing shall be held on the L7- day of-;7/(/7/f471~/'--'_,
1 ~~/P.M. In Courtroom N~( of Ihe YO;~ County Court
House, located at28 East Market Street, York, Pennsylvania 17401.
~ THIS IS AN ORDER OF COURT. ANY VIOLATION OF THIS ORDER
S~l~~NSTITUTE CONTEMPT OF COURT AND MAY BE PUNISHABLE BY A
FINE UP TO $1,000.00 AND A JAIL SENTENCE OF UP TO SIX MONTHS.
U T,
Rev. 12/94
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