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 

AFFIDAVIT OF SERVICE 

AFIDAVIT POU SÈVIS 

I, __________________________, 

the undersigned, hereby state that I 
served a copy of the Notice of Hearing 
and Order, Petition and Temporary Order 
in the above-captioned action upon 
Defendant by handing the papers to  

Mwen, _____________________, 
ki siyen non mwen anba a, sètifye mwen 
te bay Defandè a yon Avètisman Odyans 
ak Òdonans, Petisyon Pou Òdonans 
Tanporè nan pwosedi ki make anwo a lè 
mwen te bay papye yo bay  

________________________________
_________________________________ 

________________________________
_________________________________ 

t the following address:  

an adrès annapre a:  

_________________________________
_________________________________ 

_________________________________
_________________________________ 

n the ____ day of ________________, 

an ____ jou________________, 20__, 

apeprè _________ è _.m.  

I verify that the statements made in 

Mwen sètifye deklarasyon yo ki 

20__, at approximately _________ 
o’clock _.m.  
 

this Affidavit 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 
falsification to authorities.  
 

nan Afidavit sa a se verite, epi yo kòrèk.  
Mwen konprann si mwen ta bay fo 
deklarasyon nan dokiman sa a, mwen 
kapab enpoze penalite lwa 18 Pa.C.S. § 
4904, ki sou moun ki bay otorite fo 
deklarasyon  
 

  P

  _

 
 

   

  _

  a

  o

 

 

   

  _

  n

  n

   

 
 

AOPC PSVI (Haitian Creole) 

Created: December 26, 2016 

HIS FORM MUST BE COMPLETED 
AND SIGNED BY THE PERSON WHO 
SERVES THE DEFENDANT WITH THE 
NOTICE OF HEARING AND ORDER, 
PETITION AND TEMPORARY ORDER.  
IT MUST BE FILED WITH THE 
PROTHONOTARY OR BROUGHT TO 
THE COURT ON THE HEARING DATE.  
 

MOUN KI POTE AVÈTISMAN ODYANS 
AK ÒDONANS, PETISYON, AK 
ÒDONANS TANPORÈ A BAY DEFANDÈ 
A DWE RANPLI AK SIYEN FÒM SA A.  
LI DWE DEPOZE LI NAN BIWO 
PWOTO-NOTÈ A OSWA POTE LI NAN 
TRIBINAL LA JOU ODYANS LA. 

______________________________________________________ 

______________________________________________________ 

______________________________________________________ 

______________________________________________________ 

(Signature / Siyati) 

(Title / Tit) 

(Address / Adrès) 

(Date / Dat) 

  _

  _

  _

  _

    T

AOPC PSVI (Haitian Creole) 

Created: December 26, 2016