IN THE COURT OF COMMON PLEAS OF ______________ COUNTY 
DEVAN TRIBINAL PREMYE ENSTANS NAN KONTE ____________________ 

LAINTIFF / PLENYAN 

 
___________________________ 
 
                       VS. 
 
DEFENDANT / AKIZE 

__________________________ 

CASE NO. / NO. DOSYE  

__________________________ 

PROTECTION FROM ABUSE / 
PWOTEKSYON KONT ABI 

FINAL ORDER FOR PROTECTION OF 
VICTIMS OF  
  SEXUAL VIOLENCE 
  SEXUAL VIOLENCE AGAINST A 

ÒDONANS FINAL POU  PWOTEKSYON 
VIKTIM  

  VYÒL 
  VYÒL KONT YON TIMOUN MINÈ 

MINOR CHILD 
INTIMIDATION 

 

 

 

  ENTIMIDASYON 

 

Plaintiff: 
_________________________________ 

First  

Middle  

Last Name 

Pleyan an: 
_________________________________ 
  Siyati 
     Dezyèm Non 
Prenon 

laintiff’s address: 

drès Pleyan an: 

_________________________________ 
 

_________________________________ 
 

   Plaintiff’s  address 

is  confidential 

   Adrès  pleyan  an  konfidansyèl  selon 

pursuant to 42 Pa.C.S. § 62A11. 

lwa 42 Pa.C.S. § 62A11. 

efendant: 

efandè: 

_______________________________ 

First 

 

Middle  

Last Name 

_______________________________ 
  Siyati 
     Dezyèm Non 

Prenon 

efendant’s Address: 

drès Defandè an: 

________________________________ 
________________________________ 

________________________________ 
________________________________ 

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AOPC PSVI (Haitian Creole) 

Created: December 26, 2016 

 

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DEFENDANT IDENTIFIERS 

IDANTIFIKASYON DEFANDÈ A 

HEIGHT 

WEIGHT 
EYES 

STATE 

 

 
 

 

DAT 
NESANS 
SÈKS 
RAS 
KOULÈ 
CHEVE 
# SEK. 
SOSYAL 
# LISANS 
DAT EKSP. 

 

 
 

 

 

 
 

WOTÈ 

PWA KÒ 
KOULÈ ZYE 

ETA 

 

 
 

 

 

 
 
 
 

 

 

DOB 

SEX 
RACE 
HAIR 
SSN 

DRIVERS 
LICENSE # 

EXP DATE 

 

The court hereby finds that it has 
jurisdiction over the parties and the 
subject matter and that Defendant has 
been provided with reasonable notice and 
opportunity to be heard. 

ribinal la jije li gen jiridiksyon sou Pleyan 

an, Defandè a, ak zafè a epi yo te bay 
Defandè a ase avètisman ak yon 
opòtinite pou defann tèt li. 

Defendant was served in 
accordance with Pa.R.C.P. No. 1954(a) 
and provided notice of the time, date and 
location of the hearing scheduled in this 
matter. 

Yo te pote dokiman yo bay 
Defandè a konfòmeman ak Pa.R.C.P. No. 
1954(a) epi yo te avèti li lè, dat, ak kote 
yo te pwograme odyans pou zafè sa a. 

rder Effective Date: ________________   
Order Expiration Date: _______________ 

at Òdonans La Kòmanse: __________   
Dat Òdonans La Ekspire: ____________ 

AND NOW, this ____________ 

 
day of ______________, 20__, upon 
consideration of the attached Petition for 
Protection of Victims of Sexual Violence 
or Intimidation, the court hereby enters 
the following Final Order:  

 
EPI KOUNYE A,  ____________ 
jou  ______________, 20__, apre nou te 
fin konsidere Petisyon Pou Pwoteksyon 
Viktim Kont Vyòl oswa Entimidasyon ki 
vini ak dokiman sa a, tribinal la enskri 
Òdonans Final sa a:  

t is ORDERED, ADJUDGED AND 
DECREED as follows: 

sa yo: 

ou ÒDONE, JIJE, AK DEKRETE bagay 

This order is entered (check one) 

 by agreement 

 by agreement; 
 after a hearing 
without an admission; 
and decision by the court; 
 after a 
hearing at which Defendant was not 
present, despite proper service being 
made; 
how the order was entered, this is a final 

 by default.  Without regard as to 

 selon akò; 

Òdonans sa a enskri (chwazi 
 akò san yon 
 apre yon odyans ak 

youn) 
rekonesans; 
desizyon jij la; 
Defandè a pa te la, malgre yo te pote 
dokiman yo ba li kòmsadwa;  

 apre yon odyans kote 

 otomatikman.  San gade sou fason yo 

te enskri òdonans la, sa a se yon 

 

   

   

   

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AOPC PSVI (Haitian Creole) 

Created: December 26, 2016 

order of court subject to full enforcement 
pursuant to the Protection of Victims of 
Sexual Violence or Intimidation Act.  

òdonans final tribinal la yo sipoze 
respekte tout sa ki ladan konfòmeman ak 
Lwa Pwoteksyon Viktim Vyòl oswa 
Entimidasyon an.  

 Plaintiff’s request for a final protection 

 Nou refize demann Pleyan an pou yon 

order is denied.  

pwoteksyon final.  

  OR 

  OSWA 

 Plaintiff’s request for a final protection 

 Nou akòde Pleyan an demann li pou 

order is granted.  

yon pwoteksyon final.  

The following person is protected 

Men kimoun ki gen pwoteksyon 

under this order: 
_________________________________
_________________________________  

sou òdonans sa a: 
_________________________________
_________________________________  

. 

Defendant is: 

. 

Nou entèdi Defandè a: 

 A.  Restrained from having any 

contact with the victim, including, but not 
limited to, entering the victim’s residence, 
place of employment, business or school.  

 A.  Pran okenn kontak ak viktim sa. 
Sa gen ladan pa antre kote viktim nan 
rete, kote l ap travay, biznis li, oswa lekòl 
li.  

 B.   Prohibited from indirect contact 

 B.   Itilize lòt moun pou pran kontak 

with the victim through third parties. 

endirèk ak viktim nan. 

 C.  Prohibited from direct or indirect 

contact with the following designated 
persons: 
_________________________________
_________________________________ 

 C.  Itilize lòt moun yo nome pou pran 
kontak dirèk oswa endirèk ak viktim nan: 

________________________________
_________________________________ 

     

   

 

   

   

   

. 

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    2

 

 D.   Ordered to pay the fees of this 

 D.   Nou pase Defandè a lòd pou peye 

action.   
 

frè pou pwosedi sa a.   
 

AOPC PSVI (Haitian Creole) 

Created: December 26, 2016 

   

   

 

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  3.  Additional relief, including, but not 

  3.  Plis pwoteksyon, tankou pase yon 

òdonans selon 42 Pa.C.S. § 62A11(b) 
pou pa pataje adrès viktim nan, nimewo 
telefòn li, ki kote li ye oswa lòt 
enfòmasyon demografik:  

________________________________
_________________________________
_________________________________
_________________________________
_________________________________ 
 

  4.  Paske te gen yon kontestasyon 

kont òdonans sa a, oswa te gen yon 
odyans kote Defandè a pa te la, malgre 
yo te pote papye petisyon, òdonans 
tanporè ak avètisman sou dat, lè ak kote 
odyans la ap fèt kòmsadwa, nou òdone 
Defandè a pou li peye yon lòt $100 bay 
tribinal la, epi y ap distribye li jan sa 
prezante nan 42 Pa.C.S. § 62A05(c.1).  

  5.  ÒDONANS SA A RANPLASE 
NENPÒT PWOTEKSYON VIKTIM VYÒL 
OSWA ENTIMIDSAYON MENM PLEYAN 
AN TE GEN POU MENM DEFANDÈ A 
AVAN.  
 

 
AVÈTISMAN POU DEFANDÈ A 

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 other 
demographic information: 
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________ 
 

  4.  Because this order followed a 
contested proceeding, or a hearing at 
which Defendant was not present, despite 
being served with a copy of the petition, 
temporary order and notice of the date, 
time and place of the hearing, Defendant 
is ordered to pay an additional $100 
surcharge to the court, which shall be 
distributed in the manner set forth in 42 
Pa.C.S. § 62A05(c.1).  
 

  5.  THIS ORDER SUPERSEDES 

ANY PRIOR PROTECTION OF VICTIMS 
OF SEXUAL VIOLENCE OR 
INTIMIDATION ORDER OBTAINED BY 
THE SAME PLAINTIFF AGAINST THE 
SAME DEFENDANT.  
 
NOTICE TO THE DEFENDANT 

   

Defendant is hereby notified that 

Nan dokiman sa a nou avèti 

violation of this order may result in arrest 
for indirect criminal contempt.  Under 18 
U.S.C. § 2265, an order entered by the 
court may be enforceable in all fifty (50) 
States, the District of Columbia, 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 

Defandè a yo kapab arete li pou 
dezobeyisans kriminèl endirèk si li ta 
vyole òdonans sa a.  Selon lwa 18 U.S.C. 
§ 2265, yo gen dwa fè respekte yon 
òdonans ki anrejistre nan tribinal la nan 
tout senkant (50) Eta yo, Distri Columbia, 
Tè Tribal, Teritwa Ameriken, ak Pòtoriko.  
Si ou kite eta a epi ou fè eksprè ou vyole 
òdonans sa a, ou kapab gen pou ale nan 
pwosedi kriminèl nan nivo federal sou 

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AOPC PSVI (Haitian Creole) 

Created: December 26, 2016 

under the Violence Against Women Act, 
18 U.S.C. § 2262.  Consent of Plaintiff 
shall not invalidate this order, which can 
only be changed or modified through the 
filing of appropriate court papers for that 
purpose.   42 Pa.C.S. § 62A17.  
Defendant is further notified that violation 
of this order may subject him/her to 
prosecution and criminal penalties under 
the Pennsylvania Crimes Code.   

Violence Against Women Act (lwa pou 
vyolans kont fanm), 18 U.S.C. § 2262 .  
Menm si Pleyan an ta bay konsantman, 
ou p ap ka anile òdonans sa a. Se 
sèlman apre nou fin depoze papye tribinal 
pou fè sa n ap kapab chanje oswa 
modifye li.   42 Pa.C.S. § 62A17.  Nou 
avèti Defandè a tou, yo kapab pouswiv li 
nan lajistis epi enpoze penalite kriminèl 
sou Kòd Krim Pennsylvania si li vyole 
òdonans sa a.   

     

       

NOTICE TO SHERIFF, POLICE AND 
LAW ENFORCEMENT OFFICIALS 

AVÈTISMAN POU CHERIF, LAPOLIS AK 
LÒT AJAN NAN LAPOLIS 

 
The police department and sheriff 

 
 
who have jurisdiction over Plaintiff’s 
residence, the location where a violation 
of this order occurs, or where Defendant 
may be located, shall enforce this order.  
The court shall have jurisdiction over any 
indirect criminal contempt proceeding, 
either in the county where the violation 
occurred or where this protective order 
was entered.  An arrest for violation of 
paragraphs 2 and 3 of this order may be 
without warrant, based solely on probable 
cause, whether or not the violation is 
committed in the presence of the police or 
any sheriff.  42 Pa.C.S. § 62A12.  

 
 
Depatman lapolis ak cherif ki gen 
 
jiridiksyon sou rezidans Pleyan an, kote 
yo te vyole òdonans sa a, oswa kote 
Defandè a kapab ye, dwe fè respekte 
òdonans sa a.  Tribinal la ap gen 
jiridiksyon sou nenpòt pwosedi pou 
dezobeyisans endirèk kriminèl, swa nan 
konte kote vyolasyon an te fèt oswa kote 
yo te enskri òdonans pou pwoteksyon sa 
a.  Yo kapab arete Defandè a pou 
vyolasyon paragraf 2 ak 3 òdonans sa a 
san manda, epi li kapab baze sèlman sou 
kòz pwobab, kit li te komèt vyolasyon an 
devan lapolis oswa nenpòt cherif ou pa.  
42 Pa.C.S. § 62A12.  

When Defendant is placed under 

arrest for violation of the order, Defendant 
shall be taken to the appropriate authority 
or authorities before whom Defendant is 
to be arraigned.  A ‘‘Complaint for Indirect 
Criminal Contempt’’ shall then be 
completed and signed by the police 
officer, sheriff or Plaintiff.  Plaintiff’s 
presence and signature are not required 
to file the complaint.  

Lè yo arete yon Defandè paske li 
vyole òdonans la, y ap mennen Defandè 
a bay otorite ki apwopriye a pou bay 
Defandè a akizasyon ofisyèl la.  Apresa 
polis, cherif, oswa Pleyan an ap ranpli 
yon fòm "Plent Pou Dezobeyisans 
Kriminèl Endirèk" epi siyen li.  Nou pa 
bezwen Pleyan an la oswa siyen pou 
depoze plent la.  
 

   

   

 
 

AOPC PSVI (Haitian Creole) 

Created: December 26, 2016 

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If sufficient grounds for violation of 
this order are alleged: (1) Defendant shall 
be arraigned; (2) bond set, if appropriate; 
and (3) both parties shall be given notice 
of the date of the hearing. 

i yo bay ase prèv li te vyole òdonans sa 

a: (1) Y ap mennen Defandè a nan 
tribinal pou bay li akizasyon ofisyèl li; (2) 
fikse kosyon li, si sa apwopriye; epi (3) y 
ap bay Pleyan an ak Defandè a dat 
odyans la. 

Y THE COURT / POU TRIBINAL LA: 

________________________________________ 

________________________________________ 

Judge / Jij 

Date / Dat 

f a Final Order of Court is entered 
pursuant to the consent of the plaintiff 
and the defendant, both shall sign the 
order along with their counsel, if any: 

Si yo enskri yon Òdonans Final Tribinal la 
apre konsantman pleyan an ak defandè 
a, yo tou de dwa siyen òdonans la 
ansanm ak avoka yo, si genyen:  

_____________________________ 

_____________________________ 

(Plaintiff’s signature /  
Siyati pleyan an) 

(Defendant’s signature /  
Siyati defandè a) 

_____________________________ 

_____________________________ 

(Plaintiff’s attorney’s signature /  
Siyati avoka pleyan an) 
 

(Defendant’s attorney’s signature /  
Siyati avoka defandè a) 

 

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AOPC PSVI (Haitian Creole) 

Created: December 26, 2016