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ATTACHMENT А TO PETITION
ឧបសម�័ន ក ៃនពក្យបណ�ឹង
FIREARMS, OTHER WEAPONS, OR AMMUNITION INVENTORY
ប��ីកំេភ�ង អវុធេផ្សងេទៀត ឬ ្រគាប់
______________________________________________
PLAINTIFF / េដមចេម�យ
ត
លករ្រគ�សរ
ុ
FAMILY COURT DIVISION
V./ ទល់នឹង
No. / េលខ ___________________
_____________________________________________
DEFENDANT / ចុងចេម�យ
,________________________________, Plaintiff in this
Protection from Abuse Action, hereby
(a) state that Defendant used or threatened to use the
following firearms, other weapons, or ammunition against
Plaintiff or the minor child/ren (include addresses or
locations, if known such as “front seat of blue truck”, “gun
cabinet”, “bedroom closet”, etc.):
Firearm/Other Weapon/Ammunition / Location
ំ_______________________________, ជាេដមចេម�
ខ�
យៃនពក្យ
បណ�
ឹ ងករពរពីកររ ំេលភបំពនេនះ សូម
(a) ែថ�ងថា ចុងេចទបានេ្រប ឬគំរមេ្របកំេភ�
ង អវុធេផ្សងេទៀត
ឬ្រគាប់្របឆាំងនឹងេដមេចទ ឬកុមារជាអនីតិជន (ប��
ូ លអសយដ� ន ឬ
ទ
ីកែន�ង ្របសិនេបដឹង ដូចជា “េកអីមុខក�
ុងរថយន�ដឹកទំនិញពណ៌ េខៀវ”
“ទូកំេភ�
ង” “ទូបន�ប់េដក” ។ល។) :
ក
ំេភ�
ង/អវុធេផ្សងេទៀត/្រគាប់/ទីតំង
1. _____________________/_______________________ _____________________/_______________________
2. _____________________/_______________________ _____________________/_______________________
3. _____________________/_______________________ _____________________/_______________________
4. _____________________/_______________________ _____________________/_______________________
5. _____________________/_______________________ _____________________/_______________________
(b) state that Defendant, to the best of my knowledge
or belief, owns or possesses the following firearms, other
weapons, or ammunition not set forth in (a) above (include
addresses or locations, if known):
Firearm/Other Weapon/Ammunition / Location
(b) ែថ�ងថា តមករដឹង ឬជំេនឿ្របេសរបំផុតរបស់ខ�
ំ ចុងេចទមាន
ឬកន់កប់កំេភ�
ង អវុធេផ្សងេទៀត ឬ្រគាប់ ែដលមិនបានេលកេឡងដូច
(a) ខងេល (ប��
ូ លអសយដ� ន ឬទីតំង ្របសិនេបដឹង) :
ក
ំេភ�
ង/អវុធេផ្សងេទៀត/្រគាប់/ទីតំង
1. _____________________/_______________________ _____________________/_______________________
2. _____________________/_______________________ _____________________/_______________________
3. _____________________/_______________________ _____________________/_______________________
4. _____________________/_______________________ _____________________/_______________________
5. _____________________/_______________________ _____________________/_______________________
ENG/KHM PFA Pet. Attachment A
Pa. R.C.P. 1905(b) Rev. 3-19
AOPC Rev. 4-2019
1
_
_
I
ុ
ុ
(c) request that the court order Defendant to relinquish
the following firearms, other weapons, or ammunition
(include addresses or locations, if known):
(c) េស�
សុ
ំតុលករបង� ប់ចុងេចទឲ្យលះបង់កំេភ�
ង អវុធេផ្សងេទៀត ឬ
្រគាប់ដូចខងេ្រកម (ប��
ូ លអសយដ� ន ឬទីតំង ្របសិនេបដឹង)
Firearm/Other Weapon/Ammunition / Location
ក
ំេភ�
ង/អវុធេផ្សងេទៀត/្រគាប់/ទីតំង
1. _____________________/_______________________ _____________________/_______________________
2. _____________________/_______________________ _____________________/_______________________
3. _____________________/_______________________ _____________________/_______________________
4. _____________________/_______________________ _____________________/_______________________
5. _____________________/_______________________ _____________________/_______________________
All firearms, other weapons, or ammunition owned or
possessed by Defendant.
្រគប់កំេភ�
� ស់ ឬកន់កប់។
មា
ង អវុធេផ្សងេទៀត ឬ្រគាប់ទំងអស់ ែដលចុងេចទជា
If more space is needed, more sheets may be attached to
this document
ជាមួយនឹងឯកសរេនះ។
្របសិនេប្រត�វករចេនា� ះបំេពញបែន�ម អចភា� ប់សន�
ឹក្រកដសបែន�ម
Name / េឈ�ះ ___________________________________________
Date / ៃថ�ែខឆា�ំ _______________________
Notice: This attachment will be withheld from public inspection in accordance with 23 Pa.C.S. §6108(a)(7)(v).
ឧបសម�័ន�េនះនឹង្រត�វបានដកេចញពីករ្រត�តពិនិត្យសធារណៈ អនុេលមតម 23 Pa.C.S. §6108(a)(7)(v) ។
:
ណា
ំ
ំ
ច
ENG/KHM PFA Pet. Attachment A
Pa. R.C.P. 1905(b) Rev. 3-19
2
AOPC Rev. 4-2019
Khmer Petition Attachment A
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