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Home My WebLink About09-18-15 IN RE: : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA ALAN JAMES POLILLO . C� A minor child : NO. <��- �� " � / � � : ORPHANS' COURT DIVISION > c, <.�, �-> �i:l PETITION TO AMEND RECORD OF BII� ;-_� ' ' <--�' - --t, � . , �, ; � . � � AND NOW comes the Petitioner, Mandy S. Schriver, and respectfully requests - _..,� . this Honorable Court grant the following relief, and in furtherance thereto avers the f llowi�: . ; � c;� �, �-� v� , l. The subject minor child is Alan James Polillo, a male child born August l, 2013 in Holy Spirit Hospital, Camp Hill, Cumberland County, Pennsylvania. The subject minor child was born while the natural mother, Mandy S. Schriver, was married to but separated from Jason R. Schriver. 2. Petitioner, Mandy S. Schriver,the natural mother of the subject minor child, is an adult individual currently residing at 923 Herman Drive, Mechanicsburg, Cumberland County, Pennsylvania 17055. The maiden name of Petitioner, Mandy S. Schriver is Mandy S. Johnson. She is a kitchen prep cook, Caucasian, and was born in Chambersburg, Pennsylvania. She currently has three children. 3. Jonathan Lee Polillo is an adult individual currently residing at 923 Herman Drive, Mechanicsburg, Cumberland County, Pennsylvania 17055. He is a fork lift driver, Caucasian, and was born in Camp Hill, Pennsylvania. At the time of birth of the subject minor child, Alan James Polillo, he was 31 years of age. \, � 4. Jason R. Schriver is the estranged husband of the Petitioner, Mandy S. Schriver. They were married on September 27, 1997 and separated on or about August 15, 2010. While the child was born in wedlock,Jason R. Schriver is not the biological father of the subject minor child. The subject minor child's Birth Certificate states "Father's information not given" and does not specifically list Jason R. Schriver as the father. A copy of the child's Birth Certificate is attached hereto and marked E�chibit"A". 5. On December 11, 2014, Jonathan Lee Polillo signed an Acknowledgement of Paternity Wavier of Trial through the Cumberland County Domestic Relations Section, acknowledging that he is the father of the subject minor child, Alan James Polillo. A copy of the Acknowledgment of Paternity Waiver of Trial is attached hereto and marked Exhibit"B". 6. Mandy S. Schriver, Jason R. Schriver, and Jonathan Lee Polillo all desire and consent to Jonathan Lee Polillo's name being listed as the subject minor child's father on his Birth Certificate. Affidavits are attached hereto and marked Exhibit"C", Exhibit"D"and Exhibit"E". 7. At the time of the subject minor child's birth, natural mother, Mandy S. Schriver was married but separated from Jason R. Schriver and 33 years of age. As well, she was married but separated from Jason R. Schriver for a period of three years prior to the birth of the subject minor child. 8. Mandy S. Schriver and Jonathan Lee Polillo have been dating exclusively since on or about August, 2012, and Mandy Schriver has had no contact with Jason R. Schriver since on or about August 15, 2010. Petitioner Mandy S. Schriver respectfully avers that Jonathan Lee Polillo is the biological father of the subject minor child, Alan James Polillo. 9. Pursuant to 35 PS 450.603 and 35 PS 492, the Orphans Court division of the Court of Common Pleas in the State of Pennsylvania is empowered to amend the birth certificate upon good cause shown. 10. Pursuant to 20 Pa.C.S.A. § 711(9), in a11 matters which a petition is addressed to a court in connection with matters of birth records,the filing of which petition is not in the nature of an appeal but is an original proceeding, shall be filed and determined by the orphans' court division of the county in which the petitioner resides. The Petitioner, Mandy S. Schriver, currently resides in Cumberland County, Pennsylvania. 11. It is the desire of the parties that the subject minor child's birth certificate be amended to reflect that Jonathan Lee Polillo is the biological father of the subject minor child WHEREFORE Petitioner requests this Honorable Court issue an Order declaring Jonathan Lee Polillo as the father of the Birth Certificate of the subject minor child. Date: /S Respectfully Submitted, THE LAW OFFICES OF SILLIKER&REINHOLD Mark T. Silliker, Esquire 5922 Linglestown Road Harrisburg, PA 17112 I.D.No. 33671 (717) 671-1500 Attorney for Petitioner AFFIDAVIT I,/��,�/G��f�/f�i/�/� , hereby certify that the aforegoing is 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. 4909 relating to unsworn falsifications to authorities. Dated: 'r l�'�S T8 � � ��i� f �yy� y�� r u^l ',,7 !iyy •�f 2` _ I .,:. �� .i3F'', ..s3:`. ,'+if�_ 'a3f� !.��`, „� ,^ h ':: ��i`�� . � � ''T►� �` ��r�� . � � • • • . � • � � .� ;��.�� « � ,y': ��x� � � � � .�x��}��y �� h p � � ;p ,�^ �, �► '� � � �a3at�� i�. � ...�,. .•, ..,,.,. ,- • i ;`�/ �� >: �i ,:. S ... .. . . .. . .. � v •� •:.. ..__. ._....._._.__..�,_�.__.�.--'_�__..�....�.�.��_._._._�.�..w. _�.�.� ..,� �_a_�, �_�__._. _W_.._��_�M___________ ; � Certi 'cation o �irth � �� -� f �. �s{:��.� �� ¢,;��: 't'�''` Date of Birth: AUGUST 01, 2013 State File Number: 301752-2013 `� �' �� ,� Date Issued: AUGUST 28, 2013 Date Filed: AUGUST 22, 2013 � �'� �� ,'��►�" Name: ALAN ]AMES POLILLO ��1 �!a�,,� ,'w�r,,1 � , . � � Sex: MALE Time of Birth: 06:05 PM � �i.�:° Place of Birth: CUMBERLAND COUNTY � �� +� Mother's Maiden Name: MANDY SUE 70HNSON '� � �� r� � / ;� ��; `��w' �'� ��:a ��`� �\" Father's Name: INFORMATION NOT RECORDED ` � �� ?r�°'�$% ��1 �l, : " � � �� °��a � �, � �� '��$�� This is to certify that this is a true copy of the record which is on file in the Pennsylvania ,,��"'��" ��,�� a��H OF PFNy=- �,`��'1 Department of Health, in accordance with the Vital Statistics Law of 1953, as amended. ,��,�� _ J,-, �� _ `= � :� _ = ��: � Za . �r+�� ;o - ' a; �sb��"�a ��,h.vy�,s•� t�'+ �„ `�l#"`.�+�.3 �J � *; k' j ��',,rsk�;; ��' ;p -_ Z� � ,l ��!., Marina O'Reilly Matthew __�f`� _g _ ��,�P � �� . State Registrar -�9'�j.MENT��'d1, /� �� '''��iiiiiiiiiii////1�� ,�� '' '. , . . , ..� . � � :��. .; ". ' ..., ,�' . � ,,,:�' �--�-�-�''',' �-�� = -�/ �:_` .� . �-�}---�/.��.�+;� H105.105.1D Rev.(7/2012) WARNING; THIS DOCUMENT IS PRINTED ON SECUPoTV WATERMARKED PAPER � 0 0�0 9 4 5 8 2 9 DO NOT ACCEPT WITHOUT VERIFYIN THE PR SENCE OF THE WATERMARK. EXHIBR � �� .. In the Court of Common Pleas of CUMBERLAND County, Pennsylvania DOMESTIC RELATIONS SECTION MANDY S. SCHRIVER ) Docket Number: 00988 S 2014 vs. Plaintiff � ) PACSES Case Number: 473115000 JONATHAN L. POLILLO ) Defendant ) Other State ID Number: ACKNOWLEDGMENT OF PATERNITY WAIVER OF TRtAL I, JONATHAN L. POLILLO, do hereby acknowledge that I am the father of the child, ALAN J. POLILLO, born on AUGUST 1, 2013, in CAMP HILL, Cumberland County, PA. This child was born to MANDY SUE SCHRIVER, of 923 HERMAN DR, MECHANICSBURG, PA. 17055-5736-23 I have been advised of and do hereby waive my rights to (1) genetic tests on the issue of paternity, (2) a trial on the issue of paternity and (3) an attorney to represent me on the issue of paternity. 1�i�� i z /,� �r� -- ( C�--l�-�� Conference Officer/Witness Date Defendant Date Attorney for Defendant Date I verify that the statements made in this acknowledgment and waiver are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904, relating to unsworn falsific tion to authorities. � ��-��'�� Defendant Date AND NOW, this 11TH DAY OF DECEMBER, 2014 on recommendation of the Conference Officer named above, the acknowledgment of paternity and waiver of trial are accepted. BY THE COURT: � � � r � �r �+`�� Christylee L. Pac� JUDGE EXHIBIT Form PE-010 Service Type M � K �� Worker ID 21107 IN RE: : 1N THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA ALAN JAMES POLILLO . A minor child : ORPHANS COURT DIVISION : NO. AFFIDAVIT The undersigned, Mandy S. Schriver, an adult individual currently residing at 923 Herman Drive, Mechanicsburg, Cumberland County,Pennsylvania hereby voluntarily sets forth the following: 1. I am the natural mother of the subject minor child, Alan James Polillo,born August 1, 2013. 2. I fully consent and otherwise ask that this Honorable Court amend the subject minor child's birth certificate so as to reflect that the natural father of the child is Jonathan Lee Polillo. 3. My estranged husband, Jason R. Schriver, is not the biological father of the subj ect minor child. I hereby make this statement voluntarily, of my own free, fully understanding the consequences hereto. g 5 ��z� � - �,�� Witn ss Date M y S. S 'ver Date EXHIBIT � �• r� ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVAI�TIA . . SS: COUNTY OF DAUPHIN : On this��day of I , 2015, before me, a Notary Public, the undersigned officer,personally appeared Mandy S. Schriver, known to me, (or satisfactorily proven)to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official Seal. , Notary Public COMMOI.�WEALTH OF PENNSYLVANIA NOTARIAL SEAL RENEE DREISBACH,Notary Public Lower Paxton Twp.,Dauphin County My Commission Expires November 30,2018 IN RE: : 1N THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA ALAN JAMES POLILLO . A minor child : ORPHANS COURT DIVISION . NO. AFFIDAVIT The undersigned, Jason R. Schriver, an adult individual currently residing at 5 Latimore Road, Gardners, Adams County, Pennsylvania, 17324, hereby voluntarily sets forth the following: 1. I currently married to but separated from Mandy S. Schriver,the natural mother of the subject minor child,Alan James Polillo, born August l, 2013. We were married at the time of the subject minor child's birth. However, I am not the biological father of the subject minor child. 2. I fully consent and otherwise ask that this Honorable Court amend the subject minor child's birth certificate so as to reflect that the biological father of the child is Jonathan Lee Polillo. I hereby make this statement voluntarily, of my own free, fully understanding the consequences hereto. . �'� , ; .--- J ��c�.3/� � -,..`'/' '"� .�'�i _�j� __ - . , ,--�____--- it s +_ Date � son R. chriver Date �. . EXHIBf7 � � �f ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVANIA . /� �^� f : SS: COUNTY OF �-��`,�-j 1 CE.�� <� . On this ��day of v� � �� , 2015, before me, a Notary Public, the undersigned officer,personally appeared Jason k. Schriver, known to me, (or satisfactorily proven)to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official Seal. COMMCW4ti�A.LTN QF F�Nt�SYLWA,M1.� � ?�o".�r:ai Sr:;i � —•- ]psap� R.. :tria^:a ?r a;�t�ry Pubi6c �� ISI!y<r carl��. 'i r�G�. Cu�'�Ar!anG Gount'y , I My Camrnissic� 'x � � �. 13 Z018 w_r___� , , ., � .., ,, _ r. 4:��;_ Ot�S`�PUbI1C iN RE: : 1N THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA ALAN JAMES POLILLO . A minor child : ORPHANS COURT DIVISION : NO. AFFIDAVIT The undersigned, Jonathan Lee Polillo, an adult individual currently residing at 923 Herman Drive, Mechanicsburg, Cumberland County, Pennsylvania hereby voluntarily sets forth the following: 1. I am the natural father of the subject minor child,Alan James Polillo, born August 1, 2013. 2. I fully consent and otherwise ask that this Honorable Court amend the subject minor child's birth certificate so as to reflect that the natural father of the child is Jonathan Lee Polillo. 3. The husband of the natural mother, Jason R. Schriver, is not the biological father of the subject minor child. I hereby make this statement voluntarily, of my own free, fully understanding the consequences hereto. . g �� ; � � � �-j.- �_ �S� Wit ess � Date onathan Lee Polillo Date EXHIBIT � � .� ACKNOWLEDGEMENT COMMONWEALTH OF PENNSYLVA1vIA : . SS: COUNTY OF DAUPHIN : On this��day of % I , 2015, before me, a Notary Public,the undersigned officer,personally appeared Jonathan Lee Polillo, known to me, (or satisfactorily proven)to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same far the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official Seal. Notary Public iOMMONWI��i-TFi oP PENNSYLVANW NOTARIAL SEAL RENEE DREISBACH,Notary Public lower Paxton Twp.,Dauqhin Counry ��My Commission Expires Navember 30,2018