Here is the text we could read:
____________________, Plantiff
VS.
_______________________, Defendant
Case No. ____________________________
NOTICE OF HEARING AND ORDER
YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set
forth in the following papers, you must appear at the hearing scheduled herein. If you
fail to appear, the case may proceed against you and a FINAL order may be entered
against you granting the relief requested in the petition.
A hearing on the matter is scheduled for the ______ day of ________, 20__ at
____ _.m. in Courtroom __________ at _____________________Courthouse,
_________________, Pennsylvania.
If a temporary protection order has been entered, you MUST obey the order until
it is modified or terminated by the court after notice and a hearing. If you disobey that
order, the police or sheriff may arrest you. A violation of this order may subject you to a
charge of indirect criminal contempt. A violation may also subject you to prosecution
and criminal penalties under the Pennsylvania Crimes Code. 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 under the Violence Against Women Act, 18 U.S.C. § 2262.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER IMMEDIATELY. YOU HAVE
THE RIGHT TO HAVE A LAWYER REPRESENT YOU AT THE HEARING. THE
COURT WILL NOT, HOWEVER, APPOINT A LAWYER FOR YOU. IF YOU DO NOT
HAVE A LAWYER, GO TO OR CALL THE OFFICE SET FORTH BELOW. THIS
OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF
YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO
PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL
SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. IF YOU
CANNOT FIND A LAWYER, YOU MAY HAVE TO PROCEED WITHOUT ONE.
County Lawyer Referral Service
(insert Street Address)
(insert City, State, and ZIP)
(insert Phone Number)
AMERICANS WITH DISABILITIES ACT OF 1990
The Court of Common Pleas of ______________County is required by law to
comply with the Americans with Disabilities Act of 1990. For information about
accessible facilities and reasonable accommodations available to disabled individuals
having business before the court, please contact our office. All arrangements must be
made at least 72 hours prior to any hearing or business before the court. You must
attend the scheduled conference or hearing.
BY THE COURT:
______________________________________
Judge
______________________________________
Date
______________________, Plaintiff
VS.
____________________, Defendant
Case No. ____________________________
PETITION FOR PROTECTION OF VICTIMS OF
SEXUAL VIOLENCE
SEXUAL VIOLENCE AGAINST A MINOR CHILD
INTIMIDATION
Plaintiff:
1.
_____________________________________________________________________
First
Middle
Last Name
Plaintiff’s Address: ______________________________________________________
Plaintiff’s address is confidential pursuant to 42 Pa.C.S. § 62A11.
Plaintiff’s Date of Birth: _______________________________________________
I am filing this petition on behalf of
If you checked “myself,” please answer all questions referring to yourself as “Plaintiff.” If
you checked “another person,” please answer all questions referring to that person as
“Plaintiff,” and provide your name and address below.
another person.
myself or
Name: __________________________________________________________
Address: _________________________________________________________
If you checked “another person,” indicate your relationship to the plaintiff:
_____________________________________________________________________
2.
Defendant:
________________________________
First Middle
Last Name
Defendant’s Address:
________________________________
________________________________
DEFENDANT IDENTIFIERS
DOB
SEX
RACE
HAIR
SSN
DRIVERS
LICENSE #
EXP DATE
HEIGHT
WEIGHT
EYES
STATE
3.
Name(s) of other designated person(s) under 42 Pa.C.S. § 62A07(b)(1):
____________________________________________________________________
Is there a relationship between Plaintiff and Defendant? ________. If yes, what
4.
is the relationship?
_____________________________________________________________________
Have Plaintiff and Defendant been involved in any other legal proceedings? If
5.
so, state when and where the case was filed and the court docket number, if known:
_____________________________________________________________________
_____________________________________________________________________
6. Has Defendant been involved in any criminal proceedings?
______________________________________________________________________
If you answered Yes, is Defendant currently on probation or parole?
_____________________________________________________________________
7.
(a)
The facts of the most recent incident of sexual violence are as follows:
Approximate Date: ____________________________________________________
Approximate Time: ____________________________________________________
Place: ________________________________________________________________
Describe in detail what happened, including any physical or sexual abuse, threats,
injury, incidents of stalking, medical treatment sought, and/or calls to law enforcement
(attach additional sheets of paper if necessary):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
(b)
The facts of the most recent incident of intimidation are as follows:
Approximate Date: ______________________________________________________
Approximate Time: ______________________________________________________
Place: ________________________________________________________________
Describe in detail what happened, including medical treatment sought, and/or calls to
law enforcement (attach additional sheets of paper if necessary):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
If Defendant has committed prior acts of sexual violence or intimidation against
8.
Plaintiff, describe these prior incidents, and indicate approximately when such acts
occurred (attach additional sheets of paper if necessary):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Identify the sheriff, police department, or other law enforcement agency in the
9.
area in which Plaintiff lives that should be provided with a copy of the protection order:
______________________________________________________________________
Is Plaintiff in immediate and present danger from Defendant? If so please
10.
describe:
______________________________________________________________________
FOR THE REASONS SET FORTH ABOVE, I REQUEST THAT THE COURT ENTER A
TEMPORARY ORDER AND, AFTER A HEARING, A FINAL ORDER THAT WOULD
INCLUDE ALL OF THE FOLLOWING RELIEF (CHECK ALL FORMS OF RELIEF
REQUESTED):
A. Restrain Defendant from having any contact with the victim, including, but not
limited to, entering the victim’s residence, place of employment, business, or school.
B. Prohibit indirect contact through third parties.
C. Prohibit direct or indirect contact with other designated persons.
D. Order Defendant to pay the fees of this action.
E. Order the following additional relief, not listed above:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
F. Grant such other relief as the court deems appropriate, including, but not 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.
G. Order the police, sheriff or other law enforcement agency to serve the Defendant
with a copy of this petition, any order issued, and the order for the hearing. Plaintiff will
inform the designated authority of any addresses, other than Defendant’s residence,
where Defendant can be served.
VERIFICATION
I verify that the statements made in this petition are true and correct to the best of
my knowledge. I understand that false statements herein are made subject to the
penalties of 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities.
_____________________________________________________________________
Signature
_____________________________________________________________________
Date
______________________, Plaintiff
VS.
_____________________, Defendant
Case No. ____________________________
TEMPORARY ORDER FOR PROTECTION OF VICTIMS OF
SEXUAL VIOLENCE
SEXUAL VIOLENCE AGAINST A MINOR CHILD
INTIMIDATION
Plaintiff: _______________________________________________________________
First
Middle
Last Name
Plaintiff’s address: _______________________________________________________
Plaintiff’s address is confidential pursuant to 42 Pa.C.S. § 62A11.
Defendant:
________________________________
First Middle
Last Name
Defendant’s Address:
________________________________
________________________________
DEFENDANT IDENTIFIERS
DOB
SEX
RACE
HAIR
SSN
DRIVERS
LICENSE #
EXP DATE
HEIGHT
WEIGHT
EYES
STATE
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 Temporary Order:
Plaintiff’s request for a Temporary Protection Order is denied.
Plaintiff’s request for a Temporary Protection Order is granted.
The following person is protected under this order:
1.
______________________________________________________________________
2.
Defendant is:
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.
B. Prohibited from indirect contact with the victim through third parties.
C. Prohibited from direct or indirect contact with the following designated persons:
____________________________________________________________________
3. Additional relief, including, but not 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. A certified copy of this order shall be provided to the sheriff or police department
where Plaintiff resides and any other agency specified (insert name of agency):
_______________________________________________________________
5. THIS ORDER SUPERSEDES ANY PRIOR PROTECTION OF VICTIMS OF
SEXUAL VIOLENCE OR INTIMIDATION ORDER OBTAINED BY THE SAME
PLAINTIFF AGAINST THE SAME DEFENDANT.
THIS ORDER APPLIES IMMEDIATELY TO THE DEFENDANT AND SHALL
6.
REMAIN IN EFFECT UNTIL __________________ (insert expiration date) OR UNTIL
OTHERWISE MODIFIED OR TERMINATED BY THIS COURT AFTER NOTICE AND A
HEARING.
NOTICE TO THE DEFENDANT
Defendant is hereby notified that 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 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.
NOTICE TO SHERIFF, POLICE AND LAW ENFORCEMENT OFFICIALS
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.
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.
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.
BY THE COURT:
______________________________________
Judge
______________________________________
Date
rev 7-1-2015
