Here is the text we could read:
IN THE COURT OF COMMON PLEAS OF ______________ COUNTY
េ កុងតុ
របណឹងទូេ ៃនេ នធី ____________________
PLAINTIFF /េដមេ ទ
CASE NO. /សំណុំេរងេលខ__________________
___________________________
VS.
DEFENDANT /ចុងេ ទ
___________________________
PROTECTION FROM ABUSE /
រ រ រពី ររំេ ភបំ ន
PETITION FOR PROTECTION OF
VICTIMS OF
SEXUAL VIOLENCE
SEXUAL VIOLENCE AGAINST A
MINOR CHILD
INTIMIDATION
បណឹងស ប់កិច រ
រជនរងេ
ះេ យ
ំេពហិង េលផ វេភទ
ំេពហិង េលផ វេភទចំេ
អ
អ
នីតិជន
រគំ មកំ ែហង
ះកុ
រ អ
Plaintiff:
1.
__________________________________
1.
______________________________________
េដមេ ទ៖
First
Middle
Last Name
មខួន
មក ល
ម តកូល
Plaintiff’s Address:
__________________________________
សយ នរបស់េដមេ ទ៖
__________________________________
Plaintiff’s address
pursuant to 42 Pa.C.S. § 62A11.
is confidential
សយ នរបស់េដមេ ទ តវ នរក
រស ត់
េ
ង ម 42 Pa.C.S. § 62A11។
Plaintiff’s Date of Birth: _______________
ៃថែខ ំកំេណ តរបស់េដមេ ទ៖ _____________
AOPC PSVI (Cambodian / Khmer)
Created: December 26, 2016
I am filing this petition on behalf of
myself or
another person.
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.
ខុ
ំ ក់បណឹ ងេនះ ង មឲ
ខួនខុ
ំ ឬ អកេផ ង។
បសិនេបគូសយក “ខួនឯង” សូមេឆយសំណួ រ
ំង
អស់ែដល ក់ទងនឹងខួនអក "េដមេ ទ"។ បសិន
េបេ
កអកគូសយក “អកេផ ង” សូមេឆយសំណួ រ
ំងអស់ែដល ក់ទងនឹង “េដមេ ទ” េហយ
់េ
ប
ះ និង សយ នរបស់េ
កអក
េ
ែផក ងេ
ម។
Name: ____________________________
ម៖ _____________________________
Address: __________________________
សយ ន៖ ________________________
If you checked “another person,” indicate
your relationship to the plaintiff:
បសិនេបេ
កអកគូសយក “អកេផ ង” សូមប
ក
ទ
ំ ក់ទំនងរបស់េ
កអកេ នឹងេដមេ ទ៖
__________________________________ __________________________________
2.
Defendant:
2.
ច
ុងេ ទ៖
________________________________
First
Last Name
Middle
________________________________
មខួន
មក ល
ម តកូល
Defendant’s Address:
________________________________
________________________________
សយ នរបស់ចុងេ ទ៖
________________________________
________________________________
DEFENDANT IDENTIFIERS
លកណៈស ល់ចុងេ ទ
DOB
SEX
RACE
HAIR
SSN
DRIVERS
LICENSE #
EXP DATE
HEIGHT
WEIGHT
EYES
STATE
ៃថែខ ំកំេណ ត
េភទ
សក់
ព
ូជ សន៍
េលខសនិសុខសងម
ប
័ណេបកបរ#
ៃថផុតកំណត់
កមស់
ទមន់
ែភក
រដ
AOPC PSVI (Cambodian / Khmer)
Created: December 26, 2016
់
Name(s) of other designated
3.
person(s) under 42 Pa.C.S. § 62A07(b)(1):
3.
__________________________________
__________________________________
េ
ះរបស់បុគលែដល តវ ន ត់
ំង
េផ ងេទ ត
េ យេ
ង ម
42 Pa.C.S.
§
62A07(b)(1)៖
__________________________________
__________________________________
4.
Is there a relationship between
Plaintiff and Defendant? ________. If
yes, what is the relationship?
__________________________________
__________________________________
4.
ម
េតេដមេ ទ និងចុងេ ទ នទំ ក់ទំនង
ួយ ែដរឬេទ? ________។ បសិនេប ន េត
ះ ទំ ក់ទំនងអី?
េ
__________________________________
__________________________________
Have Plaintiff and Defendant been
5.
involved in any other legal proceedings? If
so, state when and where the case was
filed and the court docket number, if
known:
__________________________________
__________________________________
__________________________________
__________________________________
5.
េតេដមេ ទ និងចុងេ ទ ន រ ក់ព័នេ
កុងបណឹ ងផូវច ប់េផ ងេទ តែដរេទ? បសិនេប ន
ស
ូមប
ក
េតសំណុ
ំ េរ ងកីេ
ះ តវ ន ក់េ
េពល និងេ កែនង
ពម ំងេលខសំណុ
រ បសិនេបដឹង៖
េរ ងេ តុ
__________________________________
__________________________________
__________________________________
__________________________________
Has Defendant been involved in
6.
any criminal proceedings?
__________________________________
__________________________________
6.
េតចុងេ ទ ន រ ក់ព័ននឹងនិតិវ ិធី
ពហទណ ខះែដរឬេទ?
__________________________________
__________________________________
If you answered Yes, is Defendant
currently on probation or parole?
__________________________________
__________________________________
បសិនេបេ
កអកេឆយ
ន េតបចុប នេនះ
ច
ុងេ ទសិតេ កុង
ន ពព ួរេ ស ឬ រេលក
ែលងេ ស នលកខណែដរឬេទ?
__________________________________
__________________________________
(a)
7.
The facts of the most recent
incident of sexual violence are as follows:
7.
(a)
អងេហតុៃនេហតុ
រណ៍ អំេពហិង
េលផូវេភទថីបំផុត នដូច ងេ
ម៖
AOPC PSVI (Cambodian / Khmer)
Created: December 26, 2016
់
ំ
Approximate Date:
__________________________________
លបរ ិេចទ ប
់ បែហល៖
__________________________________
ក
Approximate Time:
__________________________________
េពលេវ
__________________________________
់ បែហល៖
ក
ប
Place:
__________________________________
ីកែនង៖
ទ
__________________________________
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):
ស
ូមពិពណ៌ លមិតអំពីអីែដល នេកតេឡង រួម ំង
សកម ពរ ំេ
ភបំ នផូវ យឬផូវេភទ រគំ ម
ក
ំែហង រេធឲ របួស េហតុ
រណ៍ េដរឈប រ
ព លេវជ សែដល នែសងរក និង/ឬ រទូរស័ព
េ
ក
រអនុវតច ប់ ( ប់មក មួយនូវសនឹក
ក សបែនម បសិនេប
ំ ច់)៖
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
(b)
The facts of the most recent
incident of intimidation are as follows:
(b) អងេហតុៃនេហតុ
ម៖
ថីៗបំផុត នដូច ងេ
រណ៍
រគំ មកំែហង
Approximate Date:
__________________________________
លបរ ិេចទ ប
់ បែហល៖
__________________________________
ក
Approximate Time:
__________________________________
លបរ ិេចទ ប
់ បែហល៖
__________________________________
ក
Place:
__________________________________
ីកែនង៖
ទ
__________________________________
AOPC PSVI (Cambodian / Khmer)
Created: December 26, 2016
់
Describe in detail what happened,
including medical treatment sought, and/or
calls to law enforcement (attach additional
sheets of paper if necessary):
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
ស
ូមពិពណ៌ លមិតអំពីអីែដល នេកតេឡង រួម ំង
រព លេវជ សែដល នែសងរក និង/ឬ
រទូរស័ពេ
ក
រអនុវតច ប់ ( ប់មក មួយនូវ
ំ ច់)៖
សនឹក ក សបែនម បសិនេប
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
If Defendant has committed prior
8.
acts of sexual violence or intimidation
against Plaintiff, describe these prior
incidents, and indicate approximately
when such acts occurred (attach additional
sheets of paper if necessary):
8.
ប
េ
បសិនេបចុងេ ទ ន ប ពឹតអំេពហិង ឬ
របំភិតបំភ័យេលផូវេភទ លពីមុនេលេដមេ ទ
ស
ូមពិពណ៌
អ
ំពីេហតុ
រណ៍ លពីមុន ំងេនះ និង
ក
់ពីេពលេវ
ប
ក
់ បែហលែដលអំេព
ំង
ះ តវ ន ប ពឹត( ប់មក មួយនូវសនឹក ក ស
បែនម បសិនេប
ំ ច់)៖
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
9.
Identify the sheriff, police
department, or other law enforcement
agency in the area in which Plaintiff lives
that should be provided with a copy of the
protection order:
__________________________________
__________________________________
9.
ស
ូមផល់អតស ណម នីនគរ ល អង ព
ឬ ក់
រអនុវតច ប់េផ ងៗេទ ត េ កុងតំបន់ែដល
េដមេ ទរស់េ
េ យ ប់ មួយនូវេសចកីចមង
ៃនដី
រ
រ៖
__________________________________
__________________________________
Is Plaintiff in immediate and present
10.
danger from Defendant? If so, please
describe:
10.
ស
ូមពិពណ៌
៖
េតេដមេ ទសិតកុង េ
ះ ក់បចុប ន
មៗ ពីសំ
ក
់ចុងេ ទែដរឬេទ? បសិនេប ន
__________________________________
__________________________________
__________________________________
__________________________________
AOPC PSVI (Cambodian / Khmer)
Created: December 26, 2016
់
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):
េ យ រែត នមូលេហតុ ងេល ខុ
ំសូមេសឲ
ត
រេចញដី បេ
ះ សន េហយេ យ
សវ
រ ដី ចុងេ យ ក់ប ូ លនូវជំនួយសេ
ំងអស់ ងេ
ម (គូសយកទ មង់ៃនជំនួយសេ
ះ
ះ
ំងអស់ែដល នេសេឡង)៖
A. Restrain Defendant from having any
A.
ក
់កំហិតមិនឲ ចុងេ ទ ក់ទង មួយ
contact with the victim, including, but not
limited to, entering the victim’s residence,
place of employment, business, or school.
ជនរងេ
ះ ដូច
រចូលេ កុងលំេ
ន កែនង
េធ
រ ជីវកម ឬ
េរ នរបស់ជនរងេ
ះ។
B. Prohibit indirect contact through
third parties.
B.
គ
ីទីបី។
ម ក់ទងេ យ បេ ល មរយៈ
C. Prohibit direct or indirect contact
C.
ម ក់ទងេ យ ល់ឬ បេ ល មួយ
with other designated persons.
ប
ុគលែដល នកំណត់េផ ងេទ ត។
D. Order Defendant to pay the fees of
D. ប
ច
ុងេ ទឲ បង់ៃថៃនចំ
ត
រេនះ។
this action.
E. Order the following additional relief,
not listed above:
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
E. ប
ឲ
នជំនួយសេ
ះបែនមេលអីែដល
ិន នេរ ប ប់ ងេល៖
ម
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
__________________________________
AOPC PSVI (Cambodian / Khmer)
Created: December 26, 2016
ុ
់
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
nondisclosure of the victim's address,
telephone number, whereabouts or other
demographic information.
F. ផល់ជំនួយសេ
េឃញ សមគួររបស់តុ
ះេផ ងៗេទ ត ម រយល់
រ ដូច
រេចញដី
ម
ួយ េ យេ
ង ម 42 Pa.C.S. § 62A11(b)
ក
់ទងនឹង រមិនប ញ សយ ន េលខទូរស័ព
កែនងកំពុងសិតេ
ឬព័ត៌ ន ប
សេផ ងៗ
េទ តរបស់ជនរងេ
ះ។
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.
G. ប
ប
ូលីស
ឬ ក់
រអនុវត
ច ប់េផ ងៗេទ ត ឲ ជួយថតចមងបណឹ ងេនះជូន
ច
ុងេ ទ ពម ំងដី
ែដល នេចញ និងដី ស ប់
សវ
រផងែដរ។ េដមេ ទនឹងជូនដំណឹ ងេ
ធរ នសមតកិច អំពី សយ នេផ ងៗេ
ព
ីលំេ
នរបស់ចុងេ ទែដលចុងេ ទ ចទទួល
េសចកីចមង ំងេនះ ន។
VERIFICATION
ល
ិខិត ប សប ក់ ពិតមិនភូតកុហក
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.
ខុ
ំសូម ប ស េសចកីែថងេ កុងបណឹ ង
េនះពិត
ត
ឹម តវពិត
កដ ម រយល់ដឹងរបស់
ខុ
ំ។ ខុ
ំយល់
េសចកីែថងមិនពិត ំឲ ខុ
ំ តវទទួល
េ ស ម 18 Pa.C.S. § 4904 ក់ព័ននឹង រែកង
ព
័ត៌ នេ យមិន ន រេធស បណិ
នចំេ
ះ
ម
ុខ
ធរ។
_____________________________________________________________________
Signature / ហតេល
_____________________________________________________________________
Date / លបរ ិេចទ
AOPC PSVI (Cambodian / Khmer)
Created: December 26, 2016
៉
