FINAL PROTECTION FROM 
ABUSE ORDER 
 Extended Order    Amended Order 

IN THE COURT OF COMMON PLEAS OF 
_____________________ COUNTY, PENNSYLVANIA 
NO. 

PLAINTIFF 

First 

Middle 

Last 

Plaintiff’s DOB 

Name(s) of all protected persons, including minor child/ren and DOB: 

_________________________________________________________________________________________________________________________ 

_________________________________________________________________________________________________________________________ 

DEFENDANT 

V. 

DOB 
SEX 
RACE 
HAIR 
SSN 
DRIVERS 
LICENSE # 
EXP 
DATE 

First 

Middle 

Last 

Suffix 

Defendant’s address: 

 DEFENDANT IDENTIFIERS 

____________________________________________________________ 

____________________________________________________________ 

HEIGHT 
WEIGHT 
EYES 

CAUTION: 
  Weapon Involved 
  Weapon Present on Property 
  Weapon Ordered Relinquished 
_________________________________________________________________________________________________ 

STATE 

 

The Court Hereby Finds:  That it has jurisdiction over the parties and subject matter, and Defendant has been provided with 
reasonable notice and opportunity to be heard. 

The Court Hereby Orders:  
  Defendant shall not abuse, harass, stalk, threaten, or attempt or threaten to use physical force against any of the above 
persons in any place where they might be found. 
  Except as provided in Paragraph 5 of this order, Defendant shall not contact Plaintiff, or any other person protected under 
      this order, by telephone or by any other means, including through third persons. 
  Additional findings of this order are set forth below. 

Order Effective Date____________________________  Order Expiration date______________________________ 
____________________________________________________________________________________________________ 

NOTICE TO DEFENDANT 

DEFENDANT IS HEREBY NOTIFIED THAT FAILURE TO OBEY THIS ORDER MAY RESULT IN ARREST AS SET FORTH IN 23 PA.C.S. § 6113 AND THAT VIOLATION 
OF THE ORDER MAY RESULT IN A CHARGE OF INDIRECT CRIMINAL CONTEMPT AS SET FORTH IN 23 PA.C.S. § 6114. VIOLATION MAY ALSO SUBJECT YOU TO 
PROSECUTION AND CRIMINAL PENALTIES UNDER THE PENNSYLVANIA CRIMES CODE.  A VIOLATION OF THIS ORDER MAY RESULT IN THE REVOCATION 
OF THE SAFEKEEPING PERMIT, WHICH WILL REQUIRE THE IMMEDIATE RELINQUISHMENT OF YOUR FIREARMS, OTHER WEAPONS, OR AMMUNITION TO 
THE SHERIFF OR THE APPROPRIATE LAW ENFORCEMENT AGENCY.  PLAINTIFF’S CONSENT TO CONTACT BY DEFENDANT SHALL NOT INVALIDATE THIS 
ORDER WHICH CAN ONLY BE MODIFIED BY FURTHER ORDER OF COURT.  23 Pa C.S. §6108(g). 

THIS ORDER IS ENFORCEABLE IN ALL FIFTY (50) STATES, THE DISTRICT OF COLUMBIA, TRIBAL LANDS, U.S. TERRITORIES, AND THE COMMONWEALTH OF 
PUERTO RICO UNDER THE VIOLENCE AGAINST WOMEN ACT, 18 U.S.C.  §2265. IF YOU TRAVEL OUTSIDE OF THE STATE AND INTENTIONALLY VIOLATE THIS 
ORDER, YOU MAY BE SUBJECT TO FEDERAL CRIMINAL PROCEEDINGS UNDER THAT ACT.  18 U.S.C. §§2261-2262.  IF YOU POSSESS A FIREARM OR ANY 
AMMUNITION WHILE THIS ORDER IS IN EFFECT, YOU MAY BE CHARGED WITH A FEDERAL CRIMINAL OFFENSE EVEN IF THIS PENNSYLVANIA ORDER DOES 
NOT EXPRESSLY PROHIBIT YOU FROM POSSESSING FIREARMS OR AMMUNITION  UNDER 18 U.S.C. §922(g)(8) OR STATE CRIMINAL OFFENSES AND STATE 
CRIMINAL PENALTIES UNDER 18 PA.C.S. § 6105.

ENGLISH/HAITIAN PFA Final Order 
Pa. R.C.P 1905(e) Rev. 3-19 

Page 1 of 9 / Paj 1 sou 9  

AOPC Rev. 4-2019 

LÒD PWOTEKSYON FINAL 
KONT MOVE TRETMAN 
 Lòd la Pwolonje    Lòd la Modifye 

DEVAN TRIBINAL PREMYE ENSTANS NAN 
KONTE _____________________, PENNSILVANI 
NIMEWO 

PLEYAN 

Prenon 

Dezyèm Non 

Siyati 

DAT NESANS Pleyan an 

Non tout moun ki pwoteje, ki gen ladan tou timoun minè a/yo ak DAT NESANS li/yo: 

____________________________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________________________ 

Kont 

AKIZE 

Prenon 

Adrès Akize a: 

Dezyèm Non 

Siyati 

__________________________________________________ 

__________________________________________________ 

IDANTITE AKIZE A 

Sifiks 

WOTÈ 
PWA 
ZYE 

DAT NESANS 
SÈKS 
RAS 
CHEVE 
NIMEWO SEKIRITE 
SOSYAL 
# LISANS 
CHOFÈ 
DAT EKSPIRASYON 

PREKOSYON: 
  Gen Zam nan ensidan an 
  Gen Zam nan kay la 
  Akize a remèt zam yo mande a 
__________________________________________________________________________________________________________ 

ETA

 

Nan dokiman sa a Tribinal la deside:  Li gen otorite sou pati yo ak sijè a, epi yo te bay Akize a avi rezonab ak opòtinite pou 
yo tande li. 

Nan dokiman sa a Tribinal la Òdone:  
  Akize a pa dwe maltrete ni pèsekite, suiv toupatou oswa menase okenn nan moun ki anwo yo kèlkanswa kote yo ta ye. 
  Eksepte jan sa ekri nan paragraf 5 lòd sa a, Akize a pa dwe kontakte Pleyan an, ni okenn lòt moun ki pwoteje anba lòd sa 

a, nan telefòn oswa pa nenpòt lòt mwayen, menm pa lentèmedyè lòt moun. 

  W ap jwenn lòt desizyon ki gen nan lòd sa a nan espas anba a. 

Dat Lòd la anvigè____________________________ 
_____________________________________________________________________________________________________ 

Dat ekspirasyon Lòd la_____________________________ 

AVI POU AKIZE A 

NAN DOKIMAN SA A, TRIBINAL LA FÈ AKIZE A KONNEN KE, SI LI DEZOBEYI LÒD TRIBINAL SA A, YO GENDWA ARETE LI DAPRE 23 PA.C.S. §6113 EPI 
VYOLASYON LÒD TRIBINAL LA GENDWA LAKÒZ YON AKIZASYON OFANS KRIMINÈL ENDIRÈK DAPRE 23 PA.C.S. §6114. SI OU VYOLE LÒD SA A OU 
GEN SIJÈ A  POUSWIT LEGAL AK SANKSYON KRIMINÈL DAPRE KÒD PENAL PENNSILVANI. SI OU VYOLE LÒD SA A, SA KAPAB FÈ TRIBINAL LA ANILE 
PÈMI POU KENBE ZAM AN SEKIRITE A, EPI TRIBINAL LA AP EGZIJE POU OU REMÈT CHERIF LA OSWA AJANS LEGAL APWOPRIYE A ZAM POU TIRE, 
LÒT KALITE ZAM AK MINISYON OU GENYEN YO.  MENM SI DEMANDÈ A DAKÒ POU AKIZE A KONTAKTE LI, SA PA ANILE LÒD SA A.  SÈL JAN POU SA 
FÈT, SE SI DEMANDÈ A DEPOZE DOKIMAN KI APWOPRIYE YO ITILIZE POU REZON SA A NAN TRIBINAL, EPI SI TRIBINAL LA BAY YON LÒD DAPRE 23 
Pa.C.S. §6108. 

YO KAPAB FÈ RESPEKTE LÒD SA A NAN TOUT SENKANT (50) ETA YO, NAN WASHINGTON, D.C., NAN TRIBI ENDYEN AMERIKEN YO, NAN TERITWA 
ETAZINI YO EPI NAN COMMONWEALTH PÒTORIKO DAPRE LWA VYOLANS KONT FANM, (VIOLENCE AGAINST WOMEN ACT), 18 U.S.C. §2265.  SI OU 
VWAYAJE AL NAN LÒT ETA EPI OU FÈ ESPRE OU VYOLE LÒD SA A, YO KAPAB KÒMANSE PWOSEDI KRIMINÈL FEDERAL KONT OU DAPRE 18 U.S.C. 
§§2261-2262.  SI OU POSEDE ZAM POU TIRE OSWA NENPÒT MINISYON PANDAN LÒD SA A ANVIGÈ, YO KAPAB POTE AKIZASYON KONT OU POU ZAK 
KRIMINÈL FEDERAL MENMSI LÒD PENNSILVANI SA A PA NESESÈMAN ENTÈDI OU POSEDE ZAM POU TIRE OSWA MINISYON DAPRE 18 U.S.C. 
§922(g)(8) OSWA ZAK KRIMINÈL ETA AK SANKSYON KRIMINÈL ETA DAPRE 18 PA.C.S. §6105 

ENGLISH/HAITIAN PFA Final Order 
Pa. R.C.P 1905(e) Rev. 3-19 

Page 2 of 9 / Paj 2 sou 9  

AOPC Rev. 4-2019 

FINAL PROTECTION FROM ABUSE ORDER 
LÒD PWOTEKSYON FINAL KONT MOVE TRETMAN  

CHECK ALL THAT APPLY: 
Plaintiff or Protected Person(s) is/are: 

TCHEKE TOUT SA KI APLIKE: 
Pleyan an oswa Moun ki pwoteje a(yo) se: 

 spouse or former spouse of Defendant
 parent of a child with Defendant
 current or former sexual or intimate partner with Defendant

 mari/madanm Akize a oswa ansyen mari/madanm
 paran yon timoun li gen ak Akize a
 patnè seksyèl oswa entim Akize a genyen kounye a oswa te

 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

Defendant was served, in accordance with Pa. R.C.P. No.
1930.4 and provided notice of the time, date, and location of
the hearing scheduled in this matter.

genyen anvan
 pitit Pleyan an
 pitit Akize a
 manm fanmi nan san (konsangen) Akize a
 fanmi Akize a pa maryaj oswa pa alyans
 frè oswa sè (moun ki gen menm papa/maman) Akize a

Yo te remèt Akize a, annakò ak Pa.R.C.P. No. 1930.4, e ba li avi
sou lè, dat, ak kikote odyans ki prevwa nan zafè sa a ap fèt.

AND NOW, this ____ day of __________, 20___, the court
having jurisdiction over the parties and the subject matter, it is
ORDERED, ADJUDGED, AND DECREED as follows:

EPI KOUNYE A, nan jou ki __________, 20___, piske tribinal la 
gen konpetans pou pati yo ak sijè a, men sa ki ÒDONE, ADJIJE E 
DEKRETE: 

This order is entered by (check one) 

Yo pran lòd sa a (Tcheke youn ladan yo) 

 By Agreement
 By Agreement without an admission
 After a hearing and decision by the Court
 After Hearing at which defendant was not present, despite
proper service being made
 By Default

 Dapre yon akò
 Dapre yon akò san yon Admisyon
 Apre yon odyans e desizyon Tribinal la
 Apre Odyans kote akize a pa te  la malgre yo te voye rekèt la
kòmsadwa
 Pa defo

Without regard as to how this order was entered, this is a
final order of court subject to full enforcement pursuant to
the Protection from Abuse Act.

San konsidere fason lòd sa a te pran, sa a se yon lòd final tribinal
ki dwe respekte nèt konfòmeman ak Lwa sou Pwoteksyon kont
Abi.

Note: Space is provided to allow for 1) the court's general
findings of abuse; 2) inclusion of the terms under which the
order was entered (e.g., that the order was entered with the
consent of the parties, or that Defendant, though properly
served, failed to appear for the hearing, or the reasons why
the plaintiff's request for a final PFA order was denied); or 3)
information that may be helpful to law enforcement (e.g.,
whether a firearm or other weapon was involved in the
incident of abuse or whether Defendant is believed to be
armed and dangerous).

Remak: Yo kite espas sa a pou 1) tribinal la ekri sa li jwenn anjeneral 
kòm move tretman; 2) mete kondisyon yo te pran lòd la (pa egzanp 
yo te pran lòd la ak konsantman tout pati yo, oswa ke Akize a, 
kwake yo te voye rekèt la kòmsadwa, pa te prezante nan odyans lan, 
oswa yo te rejte rezon yo ki te fè Pleyan an mande yon lòd PFA 
final); oswa 3) mete enfòmasyon ki gendwa itil pou lapolis (pa 
egzanp, si yon zam pou tire oswa lòt zam te prezan nan ensidan 
move tretman an oswa si yo kwè Akize a gen zam epi li danjre) 

 Plaintiff's request for a final protection order is denied.

 Yo rejte demann Pleyan an pou lòd pwoteksyon final

OR 

OSWA 

 Plaintiff's request for a final protection order is granted.

 Yo akòde demann Pleyan an pou lòd pwoteksyon final.

 1. Defendant shall not abuse, stalk, harass, threaten, or

 1. Akize a pa dwe fè abi sou li, ni pa dwe suiv toupatou, ni

attempt or threaten to use physical force against Plaintiff or
any other protected person in any place where they might be 
found. 

pèsekite, menase oswa eseye sèvi ak fòs fizik kont  Pleyan an
oswa sou nenpòt lòt moun ki sou pwoteksyon nan kèlkanswa kote yo 
ta ka ye.  

ENGLISH/HAITIAN PFA Final Order 
Pa. R.C.P 1905(e) Rev. 3-19 

Page 3 of 9 / Paj 3 sou 9  

AOPC Rev. 4-2019 

 2. Defendant is completely evicted and excluded from the

 2. Tribinal la degèpi Akize a, epi Akize a pa gen dwa rete nan kay

residence at
_______________________________________________ 
(Non-confidential address from which Defendant is excluded)
_______________________________________________ 

la ki nan

_______________________________________________ 
(Adrès ki pa konfidansyèl yo retire Akize a ladan an)
  _______________________________________________ 

or any other residence where Plaintiff or any other person 
protected under this order may live. Exclusive possession of the 
residence is granted to Plaintiff. Defendant shall have no right or 
privilege to enter or be present on the premises of Plaintiff or any 
other person protected under this order. 

oswa nan nenpòt lòt kay kote Pleyan an oubyen nenpòt lòt moun 
ki pwoteje anba Lòd sa a kapab abite. Tribinal la bay Pleyan an 
dwa pou se limenm sèlman ki rete nan kay la. Akize a pa gen 
dwa ni privilèj pou antre ni pou li prezan sou pwopriyete Pleyan 
an ni nan kay nenpòt lòt moun ki pwoteje anba Lòd sa a. 

 On

 Le

_______________________________________________ 
(Date and time) 
_______________________________________________ 

_______________________________________________ 

(Dat ak lè) 

_______________________________________________ 

Defendant may enter the residence to retrieve his/her 
clothing and other personal effects, provided that 
Defendant is in the company of a law enforcement 
officer or sheriff when such retrieval is made and (insert 
any other conditions): ___________________ 
___________________________________________ 

Akize a kapab antre nan kay la pou pran rad li ak lòt efè 
pèsonèl, akondisyon Akize a akonpaye ak yon ajan respè 
lalwa oswa cherif lè li pral pran yo ak (insert nenpòt lòt 
kondisyon): 
________________________________________________
________________________________________________ 

 3.  Except as provided in Paragraph 5 of this order, Defendant
is prohibited from having ANY CONTACT with Plaintiff, either
directly or indirectly, or any other person protected under this
order, at any location, including but not limited to any contact at
Plaintiff's school, business, or place of employment. Defendant is
specifically ordered to stay away from the following locations for
the duration of this
order:______________________________________________
______________________________________________ 
______________________________________________ 
______________________________________________ 

 4.  Except as provided in Paragraph 5 of this order, Defendant
shall not contact Plaintiff, either directly or indirectly, or any
other person protected under this order, by telephone or by any
other means, including through third persons.

 3. Eksepte jan sa ekri nan Paragraf 5, yo entèdi Akize a

gen KÈLKANSWA KONTAK avèk Pleyan an, swa dirèkteman
oubyen endirèkteman, oubyen nenpòt lòt moun 
ki pwoteje anba lòd sa a, nan nenpòt kote, tankou (men se 
pa sa yo sèlman) kontak nan lekòl Pleyan an, biznis li 
oswa kote l ap travay. Akize a resevwa lòd 
espesyalman pou rete lwen kote sa yo pandan 
tout tan lòd sa a anvigè: 

      __________________________________________________ 
__________________________________________________ 
__________________________________________________ 
__________________________________________________ 

 4. Eksepte jan sa ekri nan Paragraf 5 lòd sa a ki abòde
sipèvizyon tanporè timoun ki site nan lòd sa a, Akize a
pa dwe kontakte Pleyan an, ni dirèkteman ni endirèkteman, ni  okenn
lòt moun ki pwoteje anba lòd sa a, nan telefòn oswa pa nenpòt lòt
mwayen, menm pa lentèmedyè lòt moun.

 5. Temporary custody of the minor children, (names of the
children subject to the provision of this paragraph)

 5. Sipèvizyon tanporè timoun minè yo (non timoun yo ke
dispozisyon paragraph sa a konsène ),

_____________________________________________ 
_____________________________________________ 
_____________________________________________ 

_____________________________________________ 
_____________________________________________ 
_____________________________________________ 

      shall be as follows: 

      Dwe fèt nan jan sa a: 

Check all that apply: 
 

_____________________________________________ 
(State to whom primary physical custody is awarded; state terms of 
partial custody or visitation, if any) 
_____________________________________________ 
_____________________________________________ 
_____________________________________________ 

Tcheke tout sa ki aplike: 
 

       ___________________________________________ 
(Di kimoun yo akòde sipèvizyon fizik  prensipal; di kondisyon 
sipèvizyon pasyèl oswa vizit, si genyen) 
_____________________________________________ 
_____________________________________________ 
_____________________________________________ 

 There is a current custody order as to the

children of the parties:

______________________________________________________ 

    (County Court and docket number) 

 Gen yon lòd kounye a pou sipèvizyon konsènan

timoun toude pati yo:

__________________________________________________ 

   (Tribinal Konte ak nimewo rejis odyans) 

ENGLISH/HAITIAN PFA Final Order 
Pa. R.C.P 1905(e) Rev. 3-19 

Page 4 of 9 / Paj 4 sou 9  

AOPC Rev. 4-2019 

 A custody petition is pending.

 Yon demann pou Sipèvizyon timoun annatant.

 A hearing is scheduled for

 Yo prevwa odyans lan pou

_____________________________________________ 

_____________________________________________ 

(Date, time and location) 

(Dat, lè ak kote) 

 THIS ORDER SHALL NOT SUPERSEDE THE 
CURRENT CUSTODY ORDER 

 THIS ORDER SUPERSEDES ANY PRIOR ORDER 
RELATING TO CHILD CUSTODY 

 LÒD SA A PA RANPLASE LÒD SIPÈVIZYON 
TIMOUN KI GENYEN KOUNYE A 

 LÒD SA A RANPLASE NENPÒT LÒD ANVAN 
KONSÈNAN SIPÈVIZYON TIMOUN 

The custody provisions of Paragraph 5 of this order are 
temporary. Either party may initiate custody proceedings 
pursuant to the custody statute at 23 Pa.C.S. §§ 5321— 
5340. Any valid custody order entered after the final 
Protection From Abuse order supersedes the custody 
provisions of this order. 

Dispozisyon pou sipèvizyon ki nan paragraph 5 lòd sa a tanporè. 
Nenpòt nan pati yo gendwa kòmanse pwosedi sipèvizyon yo 
dapre estati sipèvizyon an nan 23 Pa.C.S. §§ 5321— 5340. 
Nenpòt lòd sipèvizyon valid ki pran apre lòd final Pwoteksyon 
kont Move Tretman an anile dispozisyon pou sipèvizyon lòd sa 
a.  

 6. FIREARMS, OTHER WEAPONS, OR AMMUNITION

 6. RESTRIKSYON SOU ZAM POU TIRE, LÒT ZAM, OSWA

RESTRICTIONS

Check all that apply: 

MINISYON

Tcheke tout sa ki aplike: 

 Defendant is prohibited from possessing or acquiring any
firearms for the duration of this order.

 Yo entèdi Akize a gen kontwòl oswa posede kèlkanswa
zam pou tire pandan dire lòd sa a.

 Defendant shall relinquish to the sheriff or the appropriate
law enforcement agency the following firearm licenses
owned or possessed by Defendant:
_____________________________________________

 Akize a dwe remèt cherif la oswa ajans legal apwopriye a
lisans pou zam pou tire ki annapre  a ke Akize a posede oswa
gen kontwòl sou yo.
_____________________________________________

_____________________________________________ 

_____________________________________________ 

 Defendant is directed to relinquish to the sheriff or the
appropriate law enforcement agency any firearm, other
weapon, or ammunition listed in Attachment A to the Final
Order, which is incorporated herein by reference.

 Yo egzije Akize a remèt ba cherif la kèlkanswa zam pou tire,
lòt zam oswa minisyon ki site nan Dokiman siplemantè A
Lòd Tanporè a, ki nan anèks la a pou referans.

Defendant may relinquish any firearms, other weapons, or 
ammunition to the sheriff or the appropriate law enforcement 
agency. As an alternative, Defendant may either relinquish 
firearms, other weapons, or ammunition to a third party 
provided Defendant and the third party first comply with all the 
requirements to obtain a safekeeping permit, or relinquish 
firearms, other weapons, or ammunition to a licensed firearms 
dealer for consignment sale, lawful transfer, or safekeeping 
pursuant to 23 Pa. C.S. §6108.2(e). Defendant must relinquish 
any firearm, other weapon, ammunition, or firearm license 
ordered to be relinquished no later than 24 hours after service of 
this order. Failure to timely relinquish any firearm, other 
weapon, ammunition, or any firearm license ordered to be 
relinquished shall result in a violation of this order and may 
result in criminal conviction under the Uniform Firearms Act, 
18 Pa. C.S. §6105. 

Akize a kapab remèt nenpòt zam pou tire, lòt zam oswa minisyon 
ba cherif la oswa ajans legal apwopriye a. Lòt chwa ki genyen, 
Akize a kapab remèt zam pou tire yo, lòt zam, oswa minisyon yo ba 
yon lòt moun akondisyon Akize a ak lòt moun lan te respekte 
toudabò tout kondisyon pou jwenn yon pèmi pou lagad legal zam 
pou tire oubyen remèt zam pou tire yo, lòt zam, oswa minisyon yo 
ba yon revandè zam pou tire ki gen lisans pou vant an konsiyasyon, 
transfè legal oswa lagad legal zam pou tire konfòmeman ak 23 Pa. 
C.S. §6108.2(e). Akize a dwe remèt kèlkanswa zam pou tire, lòt
zam, minisyon oswa lisans pou zam pou tire yo egzije pou li remèt
yo pa pita pase 24 èdtan apre li te resevwa Lòd sa a. Si li pa remèt
alè kèlkanswa zam pou tire, lòt zam, minisyon, oswa nenpòt lisans
pou zam pou tire yo egzije pou li remèt, sa ap yon vyolasyon Lòd sa
a epi li kapab lakòz yon kondanasyon kriminèl dapre Lwa sou Zam
pou tire (Uniform Firearms Act, 18 Pa. C.S. §6105).

 7. Any firearm delivered to the sheriff or the appropriate law
enforcement agency or transferred to a licensed firearm
dealer or a qualified third party, who satisfies the procedural 
and substantive requirements to obtain a safekeeping permit 
issued under 23 Pa C.S. §6108.3 pursuant to this order or the 
temporary order, shall not be returned to Defendant until 
further order of court or as otherwise provided by law. 

 7. Nenpòt zam pou tire yo remèt ba cherif la oswa ajans legal

apwopriye a, ba yon revandè zam pou tire ki gen lisans, oswa yon lòt
moun ki kalifye, ki respekte tout kondisyon pwosedi ak sa ki anrapò 
ak prensip legal pou jwenn yon pèmi lagad legal zam pou tire ki 
delivre annakò ak 23 Pa C.S.  §6108.3 dapre lòd sa a oswa yon lòd 
tanporè, yo pa dwe tounen yo ba Akize a jiskaske gen yon lòt lòd 
tribinal oswa si lalwa prevwa dispozisyon kontrè. 

ENGLISH/HAITIAN PFA Final Order 
Pa. R.C.P 1905(e) Rev. 3-19 

Page 5 of 9 / Paj 5 sou 9  

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 8. The Pennsylvania State Police, the municipal police, or the
sheriff shall accompany Plaintiff to his or her residence to
retrieve personal belongings. 

 8. Polis Eta Pennsilvani, polis minisipal oswa cherif la dwe ale

ak Plentif lan nan kay li pou pran zafè pèsonèl li yo

 9. The following additional relief is granted as authorized by

 9. Yo akòde lòt reparasyon sa a tou jan seksyon §6108 Lwa a

§6108 of the Act:
_____________________________________________
_____________________________________________
_____________________________________________

otorize a:
________________________________________________
________________________________________________
________________________________________________

 Defendant is prohibited from stalking, as
defined in 18 Pa. C.S. §2709.1, or harassing, as
defined in 18 Pa. C.S. §2709, the following family
and household members of Plaintiff:

 Yo entèdi Akize a suiv toupatou, jan sa
defini nan 18 Pa. C.S. §2709.1, oswa pèsekite,
jan sa defini nan 18 Pa. C.S. §2709, manm fanmi
ak moun nan kay Pleyan an ki annapre la yo:

Name / Non 

Address / Adrès 

Relationship to Plaintiff / 
Kisa yo ye pou Pleyan an 

 Other relief:
_________________________________________
_________________________________________

 Lòt reparasyon:
____________________________________________
____________________________________________

 10. Defendant is directed to pay temporary support for:

 10. Yo bay Akize a lòd pou peye sipò tanporè pou:

_____________________________________________
_____________________________________________ 

(Names of the persons for whom support is to be paid) 

as follows: 
_____________________________________________ 
_____________________________________________ 
_____________________________________________ 
(Amount, frequency and other terms and conditions of the Support Order) 

_____________________________________________
_____________________________________________ 

(Non moun li dwe peye sipò pou yo a) 

nan fason sa a: 
_____________________________________________ 
_____________________________________________ 
_____________________________________________ 
(Montan, konbyen fwa ak lòt kondisyon jeneral Lòd Sipò a) 

This order for support shall remain in effect until a final 
support order is entered by this court.  However, this 
order shall lapse automatically if Plaintiff does not file a 
complaint for support with the Domestic Relations 
Section of the court within two weeks of the date of this 
order.  The amount of this temporary order does not 
necessarily reflect Defendant's correct support 
obligation, which shall be determined in accordance 
with the guidelines at the support hearing.  Any 
adjustments in the final amount of support shall be 
credited, retroactive to this date, to the appropriate party. 

Lòd pou sipò sa a ap rete anvigè jiskaske tribinal sa a 
pran yon lòd final.  Sepandan, lòd sa a ap ekspire 
otomatikman si Pleyan an pa depoze yon plent pou sipò 
nan Seksyon Relasyon Familyal tribinal la anvan de 
semèn fin pase apre dat lòd sa a.  Montan lòd tanporè sa 
a pa nesesèman endike montan egzak Akize a oblije 
peye pou sipò a.  Y ap kalkile montan an dapre prensip 
ki genyen yo lè y ap fè odyans pou sipò a.  Y ap fè 
koreksyon nan montan final sipò a, epi y ap bay moun ki 
apwopriye a kredi li merite a, apati dat sa a. 

 11.   (a) The costs of this action are imposed on

 11.  (a) Se Akize a ki responsab depans yo pou ka sa a.

Defendant. 

 (b) Because this order followed a contested
proceeding, or a hearing at which the 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 23 Pa. C.S.
§6106(d).

 (c) Upon a showing of good cause or finding that
Defendant is unable to pay, the costs of this action are
waived.

 (b) Poutèt lòd sa a te suiv yon pwosedi konteste,
oswa yon jijman kote Akize a pa te prezan, malgre yo
te remèt li yon kopi demann lan, lòd tanporè a ak
avètisman sou dat, lè ak plas kote odyans lan ap fèt, yo
bay Akize a lòd pou peye tribinal la yon chaj anplis ki
$100, ke yap separe nan fason ki tabli nan 23 Pa. C.S.
§6106(d).

 (c) Si li montre yon rezon valab oswa si yo jwenn
Akize a pa kapab peye, y ap anile depans yo pou ka sa
a.

ENGLISH/HAITIAN PFA Final Order 
Pa. R.C.P 1905(e) Rev. 3-19 

Page 6 of 9 / Paj 6 sou 9  

AOPC Rev. 4-2019 

 12. Defendant shall pay $ ____________ to Plaintiff by

___________________ as compensation for Plaintiff’s 

12.  Akize a dwe peye Pleyan an $ ____________ anvan
___________________ kòm dedomajman pou lajan 

   (Date) 

   (Dat) 

out-of-pocket losses, which are as follows: 
_____________________________________________ 
_____________________________________________ 
_____________________________________________ 

ki soti nan pòch Pleyan an nan fason sa a: 
_____________________________________________ 
_____________________________________________ 
_____________________________________________ 

 An installment Schedule is ordered as follows:
_____________________________________________
_____________________________________________
_____________________________________________

 Men Kalandriye vèsman pa tranch yo òdone a:
_____________________________________________
_____________________________________________
_____________________________________________

OR 

OSWA 

 Plaintiff is granted leave to present a petition, with
appropriate notice to Defendant, to _________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
  (Insert name of Judge or court to which the petition should be presented) 

 Yo akòde Pleyan an otorizasyon pou prezante yon
demann, ak avi apwopriye ba akize a, ba ____________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
(Mete non Jij oswa tribinal yo dwe prezante demann lan ba li a) 

requesting recovery of out-of-pocket losses. The  
petition shall include an exhibit itemizing all claimed  
out-of-pocket losses, copies of all bills and estimates of  
repair, and an order scheduling a hearing. No fee shall  
be required by the prothonotary’s office for the filing of 
this petition. 

pou mande rekipere lajan ki soti nan pòch li. Demann lan 
dwe gen ladan yon pyès ki detaye tout pèt li reklame yo, 
kopi tout bòdwo ak estimasyon reparasyon epi yon lòd ki 
prevwa yon odyans. Biwo pwotonotè a pa dwe mande frè 
pou depo demann sa a. 

 13. THIS ORDER SUPERSEDES ANY PRIOR

 13. LÒD SA A RANPLASE NENPÒT PWOTEKSYON

PROTECTION FROM ABUSE ORDER OBTAINED 
BY THE SAME PLAINTIFF AGAINST THE SAME 
DEFENDANT. 

KONT MOVE TRETMAN MENM DEMANDÈ A TE 
GENYEN ANVAN KONT MENM AKIZE A. 

 14. All provisions of this order shall expire

 14. Tout dispozisyon ki nan lòd sa a ap ekspire

 (Check one): 

 (Tcheke youn): 

 in _________________, on _________________

  (Days, months or years)

(Date) 

 nan _________________, le _________________

  (Kantrite jou,mwa,oswa ane)

(Dat) 

OR 

OSWA 

 in three years on
__________________________________________.

(Expiration Date)

 nan twa ane le
__________________________________________.
(Dat Ekspirasyon)

ENGLISH/HAITIAN PFA Final Order 
Pa. R.C.P 1905(e) Rev. 3-19 

Page 7 of 9 / Paj 7 sou 9  

AOPC Rev. 4-2019 

NOTICE TO DEFENDANT 

DEFENDANT IS HEREBY NOTIFIED THAT FAILURE TO OBEY THIS ORDER MAY RESULT IN ARREST AS 

SET FORTH IN 23 PA.C.S. § 6113 AND THAT VIOLATION OF THE ORDER MAY RESULT IN A CHARGE OF INDIRECT 
CRIMINAL CONTEMPT AS SET FORTH IN 23 PA.C.S. § 6114. VIOLATION MAY ALSO SUBJECT YOU TO 
PROSECUTION AND CRIMINAL PENALTIES UNDER THE PENNSYLVANIA CRIMES CODE. A VIOLATION OF THIS 
ORDER MAY RESULT IN THE REVOCATION OF THE SAFEKEEPING PERMIT, WHICH WILL REQUIRE THE 
IMMEDIATE RELINQUISHMENT OF YOUR FIREARMS, OTHER WEAPONS, AND AMMUNITION TO THE SHERIFF OR 
THE APPROPRIATE LAW ENFORCEMENT AGENCY. PLAINTIFF’S CONSENT TO CONTACT BY DEFENDANT SHALL 
NOT INVALIDATE THIS ORDER, WHICH CAN ONLY BE MODIFIED BY FURTHER ORDER OF COURT. 23 Pa. C.S. 
§6108(g).

THIS ORDER IS ENFORCEABLE IN ALL FIFTY (50) STATES, THE DISTRICT OF COLUMBIA, TRIBAL LANDS, 
US TERRITORIES, AND THE COMMONWEALTH OF PUERTO RICO UNDER THE VIOLENCE AGAINST WOMEN ACT, 
18 U.S.C. §2265. IF YOU TRAVEL OUTSIDE OF THE STATE AND INTENTIONALLY VIOLATE THIS ORDER, YOU MAY 
BE SUBJECT TO FEDERAL CRIMINAL PROCEEDINGS UNDER THAT ACT. 18 U.S.C. §§2261-2262. IF YOU POSSESS A 
FIREARM OR ANY AMMUNITION WHILE THIS ORDER IS IN EFFECT, YOU MAY BE CHARGED WITH A FEDERAL 
CRIMINAL OFFENSE EVEN IF THIS PENNSYLVANIA ORDER DOES NOT EXPRESSLY PROHIBIT YOU FROM 
POSSESSING FIREARMS OR AMMUNITION UNDER 18 U.S.C. §922(g)(8) OR STATE CRIMINAL OFFENSES AND 
STATE CRIMINAL PENALTIES UNDER 18 PA.C.S. § 6105. 

AVI POU AKIZE A 

NAN DOKIMAN SA A, TRIBINAL LA FÈ AKIZE A KONNEN KE, SI LI DEZOBEYI LÒD TRIBINAL SA A, YO GENDWA 

ARETE LI DAPRE 23 PA.C.S. §6114 EPI VYOLASYON LÒD TRIBINAL LA GENDWA LAKÒZ YON AKIZASYON OFANS 
KRIMINÈL ENDIRÈK DAPRE 23 PA.C.S. §6114..  SI OU VYOLE LÒD SA A, SA KAPAB FÈ YO POUSWIV OU NAN TRIBINAL 
EPI YO KA PRAN SANKSYON KRIMINÈL KONT OUMENM DAPRE KÒD PENAL PENNSILVANI AN.  SI OU VYOLE LÒD SA 
A, SA KAPAB FÈ TRIBINAL LA ANILE PÈMI POU KENBE ZAM AN SEKIRITE A, EPI TRIBINAL LA AP EGZIJE POU OU 
REMÈT CHERIF LA OSWA AJANS LEGAL APWOPRIYE A ZAM POU TIRE, LÒT KALITE ZAM AK MINISYON OU GENYEN 
YO IMEDYATMAN.  MENM SI DEMANDÈ A DAKÒ POU AKIZE A KONTAKTE LI, SA PA ANILE LÒD SA A.  SÈL JAN POU SA 
FÈT, SE SI DEMANDÈ A DEPOZE DOKIMAN APWOPRIYE YO ITILIZE NAN TRIBINAL POU REZON SA A, EPI SI TRIBINAL 
LA BAY YON LÒD ANPLIS DAPRE 23 Pa.C.S. §6108(g). 

YO KAPAB FÈ RESPEKTE LÒD SA A NAN TOUT SENKANT (50) ETA YO, NAN DISTRICT OF COLUMBIA, NAN 

TRIBI ENDYEN AMERIKEN YO, NAN TERITWA ETAZINI YO EPI NAN COMMONWEALTH PÒTORIKO DAPRE LWA SOU 
VYOLANS KONT FANM, (VIOLENCE AGAINST WOMEN ACT), 18 U.S.C. §2265.  SI OU VWAYAJE AL NAN LÒT ETA EPI OU 
FÈ ESPRE OU VYOLE LÒD SA A, YO KAPAB KÒMANSE PWOSEDI KRIMINÈL FEDERAL KONT OU DAPRE 18 U.S.C. 
§§2261-2262.  SI OU POSEDE ZAM POU TIRE OSWA NENPÒT MINISYON PANDAN LÒD SA A ANVIGÈ, YO KAPAB POTE
AKIZASYON KONT OU POU ZAK KRIMINÈLFEDERAL MENMSI LÒD PENNSILVANI SA A PA NESESÈMAN ENTÈDI OU
POSEDE ZAM POU TIRE OSWA MINISYON DAPRE 18 U.S.C. §922(G)(8) OSWA ZAK KRIMINÈL ETA AK SANKSYON
KRIMINÈL ETA DAPRE 18 PA.C.S.U §6105.

NOTICE TO SHERIFF, POLICE, AND LAW ENFORCEMENT OFFICIALS 

The police and sheriff who have jurisdiction over Plaintiff's residence OR any 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 1 through 7 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. 23 Pa. C.S. §6113. 

Subsequent to an arrest, and without the necessity of a warrant, the police officer or sheriff shall seize all 

firearms, other weapons, and ammunition in Defendant's possession that were used or threatened to be used during the 
violation of the protection order or during prior incidents of abuse and any other firearms in Defendant's possession.  

The______________________________________________________________________________________ 

shall maintain possession of firearms, other weapons, or ammunition until further order of the court. 

(Insert the appropriate name or title) 

ENGLISH/HAITIAN PFA Final Order 
Pa. R.C.P 1905(e) Rev. 3-19 

Page 8 of 9 / Paj 8 sou 9  

AOPC Rev. 4-2019 

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 this complaint. 

If sufficient grounds for violation of this order are alleged, Defendant shall be arraigned, bond set, if 

appropriate, and both parties given notice of the date of the hearing. 

AVI POU CHERIF, LAPOLIS, AK OTORITE RESKONSAB APLIKASYON LALWA 

Lapolis oswa cherif ki gen otorite sou kote Demandè a rete a OSWA nenpòt kote yo vyole lòd sa a OSWA kote 

yo kapab jwenn Akize a ki dwe fè respekte lòd sa a.  Tribinal la gen otorite sou nenpòt pwosedi pou dezobeyisans 
kriminèl endirèk, swa nan konte kote yo vyole lòd la oswa kote tribinal la te bay lòd pwoteksyon an.  yo dwe arete Akize 
a epi pouswiv li pou Dezobeyisans Kriminèl Endirèk.  Yo kapab poze yon arestasyon pou vyolasyon kondisyon ki nan 
Paragraf 1 jiska 7 nan Lòd sa a san yon manda arestasyon, pou kòz posib sèlman, kit se nan prezans yon ajan lapolis 
oswa nenpòt cherif vyolasyon lòd la te fèt. 23 Pa. C.S. §6113. 

Apre yon arestasyon, epi san yon manda pa nesesè, ajan lapolis la oswa cherif la dwe sezi tout zam pou tire, lòt 

zam ak minisyon Akize a posede epi li te itilize yo oswa li te menase pou itilize yo lè li t ap vyole lòd pwoteksyon an 
oswa pandan ensidan move tretman ki te pase anvan, ansanm ak nenpòt lòt zam pou tire.  

______________________________________________________________________________________ 

dwe konsève posesyon zam pou tire yo, lòt zam oswa minisyon yo jiska yon nouvo lòd tribinal la. 

(Mete non oswa tit ki apwopriye a) 

Lè yo arete Akize a pou vyolasyon lòd la, yo dwe mennen Akize a ba otorite apwopriye a oswa otorite yo ki pral chaje 
Akize a pou krim lan. Ajan lapolis la, cherif la OSWA Pleyan an dwe ranpli e siyen yon "Plent pou Dezobeyisans 
Kriminèl Endirèk". Pleyan an pa oblije prezan epi siyati li pa nesesè pou depoze plent sa a. 

Si gen rezon sifizan pou afime vyolasyon lòd sa a, yo dwe mete defandè a ann akizasyon, fikse bel (kosyon), si 

sa nesesè epi avèti toude pati yo sou dat odyans. 

BY THE COURT / SIYATI TRIBINAL LA, 

_________________________________________ 

_________________________________________ 

Judge / Jij 

Date / Dat 

This order was entered pursuant to the consent of Plaintiff and Defendant: 
 Tribinal la pase lòd la dapre konsantman Pleyan an ak Akize a: 

______________________________________________ 
Plaintiff’s signature (Siyati Pleyan an) 

    

____________________________________________ 
Defendant's signature (Siyati Akize a) 

______________________________________________ 
Attorney for Plaintiff’s signature 
(Siyati Avoka Pleyan an) 

____________________________________________ 
Attorney for Defendant’s signature 
(Siyati Avoka Akize a) 

ENGLISH/HAITIAN PFA Final Order 
Pa. R.C.P 1905(e) Rev. 3-19 

Page 9 of 9 / Paj 9 sou 9  

AOPC Rev. 4-2019