IN THE COURT OF COMMON PLEAS OF _________________________ COUNTY  
 
ﺔﻌطﺎﻘﻤﻟ ﺔﻣﺎﻌﻟا ﺔﯿﺋاﺪﺘﺑﻻا ﺔﻤﻜﺤﻤﻟا ﻲﻓ
_________________________

 

_______________________________________________ 
PLAINTIFF  / ﻲﻋﺪﻤﻟا 

FAMILY  COURT  DIVISION 
 
ةﺮﺳﻷا
 ﺔﻤﻜﺤﻣ ﻢﺴﻗ

V./ ﺪﺿ 

No.  / ﻢﻗر ___________________ 

______________________________________________
DEFENDANT  / ﮫﯿﻠﻋ ﻰﻋﺪﻤﻟا 

ATTACHMENT А TO PETITION 
ﻖﺤﻠﻣ 
ا
 
ﻻ
ﻟ
ﺘ
ﻤ
ﺎ
س
أ
 
 

FIREARMS, OTHER WEAPONS, OR AMMUNITION INVENTORY  
ﺧﺬﻟا وأ ىﺮﺧﻷا ﺔﺤﻠﺳﻷاو ﺔﯾرﺎﻨﻟا ﺔﺤﻠﺳﻷا ﺔﻤﺋﺎﻗ
ﯿ
ﺮ
ة

I,________________________________, 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.): 

 ﺔﯿﻀﻗ ﻲﻓ ﻲﻋﺪﻤﻟا ،________________________________،ﺎﻧأ
 ،ﮫﺒﺟﻮﻤﺑ ،هﺬھ ةءﺎﺳﻹا ﻦﻣ ﺔﯾﺎﻤﺤﻟا

 ﺔﯾرﺎﻨﻟا ﺔﺤﻠﺳﻷا لﺎﻤﻌﺘﺳﺎﺑ دﺪھ وأ ﻞﻤﻌﺘﺳا ﮫﯿﻠﻋ ﻰﻋﺪﻤﻟا نﺄﺑ ﺮﻗأ (أ)
 ﺮﺻﺎﻘﻟا (لﺎﻔطﻷا) ﻞﻔﻄﻟا وأ ﻲﻋﺪﻤﻟا ﺪﺿ ﺔﯿﻟﺎﺘﻟا ةﺮﯿﺧﺬﻟا وأ ىﺮﺧﻷا ﺔﺤﻠﺳﻷاو
 ﺔﻨﺣﺎﺸﻠﻟ ﻲﻣﺎﻣﻷا ﺪﻌﻘﻤﻟا" ﻞﺜﻣ ،ﺎﮭﻓﺮﻌﺗ ﺖﻨﻛ لﺎﺣ ﻲﻓ ،ﻊﻗاﻮﻤﻟا وأ ﻦﯾوﺎﻨﻌﻟا ﺮﻛذا)
 :(.ﺦﻟا ،"مﻮﻨﻟا ﺔﻓﺮﻏ ﺔﻧاﺰﺧ" ،"ﺔﯿﻗﺪﻨﺒﻟا ﺔﻧاﺰﺧ" ،"ءﺎﻗرﺰﻟا

Firearm/Other  Weapon/Ammuni tion  / Location 

ﻊﻗﻮﻤﻟا /  ةﺮﯿﺧﺬﻟا/ىﺮﺧﻷا ﺔﺤﻠﺳﻷا/ﺔﯾرﺎﻨﻟا ﺔﺤﻠﺳﻷا 

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): 

 ﺐﺴﺣو تﺎﻣﻮﻠﻌﻣ ﻦﻣ يﺪﻟ ﺎﻣ ﻞﻀﻓأ ﺐﺴﺣ ،ﮫﯿﻠﻋ ﻰﻋﺪﻤﻟا نﺄﺑ ﺮﻗأ (ب)

 ﺔﯿﻟﺎﺘﻟا ةﺮﯿﺧﺬﻟاو ىﺮﺧﻷا ﺔﺤﻠﺳﻷاو ﺔﯾرﺎﻨﻟا ﺔﺤﻠﺳﻷا ﮫﺗزﻮﺤﺑ وأ ﻚﻠﺘﻤﯾ ،يدﺎﻘﺘﻋا
 :(ﺎﮭﻓﺮﻌﺗ ﺖﻨﻛ اذإ ،ﻊﻗاﻮﻤﻟا وأ ﻦﯾوﺎﻨﻌﻟا ﺮﻛذا) هﻼﻋأ (أ) ةﺮﻘﻓ ﻲﻓ ﺔﻨﯿﺒﻤﻟا ﺮﯿﻏ

Firearm/Other  Weapon/Ammuni tion  / Location 

 

ﻊﻗﻮﻤﻟا  /    ةﺮﯿﺧﺬﻟا/ىﺮﺧﻷا ﺔﺤﻠﺳﻷا/ﺔﯾرﺎﻨﻟا ﺔﺤﻠﺳﻷا

1. _____________________/_______________________
2. _____________________/_______________________
3. _____________________/_______________________
4. _____________________/_______________________
5. _____________________/_______________________

 _____________________/_______________________ 
   _____________________/_______________________ 
   _____________________/_______________________ 
   _____________________/_______________________ 
   _____________________/_______________________ 

ENGLISH/ARABIC  PFA Pet. Attachment A 
Pa. R.C.P. 1905(b) Rev. 3-19 

 
1 

AOPC Rev. 4-2019 

(c)

request that the court order Defendant to relinquish

 ﺔﺤﻠﺳﻷاو ﺔﯾرﺎﻨﻟا ﺔﺤﻠﺳﻷا ﻢﯿﻠﺴﺘ

ﺑ ﮫﯿﻠﻋ ﻰﻋﺪﻤﻟا ﺔﻤﻜﺤﻤﻟا ﺮﻣﺄﺗ نأ ﺐﻠ

طأ (ج)

 

:(ﺎﮭﻓﺮﻌﺗ  ﺖﻨﻛ اذإ ،ﻊﻗاﻮﻤﻟا وأ ﻦﯾوﺎﻨﻌﻟا  ﺮﻛذا) ﺔﯿﻟﺎﺘﻟا ةﺮﯿﺧﺬﻟاو ىﺮﺧﻷا

the following firearms, other weapons, or ammunition 
(include addresses or locations, if known): 

Firearm/Other  Weapon/Ammuni tion  / Location 

 

ﻊﻗﻮﻤﻟا  /    ةﺮﯿﺧﺬﻟا/ىﺮﺧﻷا ﺔﺤﻠﺳﻷا/ﺔﯾرﺎﻨﻟا ﺔﺤﻠﺳﻷا

1. _____________________/_______________________
2. _____________________/_______________________
3. _____________________/_______________________
4. _____________________/_______________________
5. _____________________/_______________________

 _____________________/_______________________ 
   _____________________/_______________________ 
   _____________________/_______________________ 
   _____________________/_______________________ 
   _____________________/_______________________ 

  All firearms,  other weapons, or ammunition  owned or 
possessed by Defen dant. 

 ﻰﻋﺪﻤﻟا

 

ﺎﮭﻜﻠﺘﻤﯾ ﻲﺘﻟا

 ةﺮﯿﺧﺬﻟاو  ىﺮﺧﻷا ﺔﺤﻠﺳﻷاو ﺔﯾرﺎﻨﻟا ﺔﺤﻠﺳﻷا ﻊﯿﻤﺟ
  وأ 

زﺎﯿﺣ ﻲﻓ
 
ةدﻮﺟﻮﻣ

ﮫﺗ. 

   
ﮫﯿﻠﻋ

If more  space is needed, more  sheets may  be attached to 
this  document  

 

ﺔﻘﯿﺛﻮﻟا هﺬﮭﺑ ىﺮﺧأ قاروأ قﺎﺤﻟإ ﻚﻨﻜﻤﯾ  ،ﺔﯿﻓﺎﺿإ ﺔﺣﺎﺴﻣ ﻰﻟإ ﺖﺠﺘﺣا لﺎﺣ ﻲﻓ

Name  / ﻢﺳﻻا ___________________________________________   

 Date / ﺦﯾرﺎﺘﻟا ________________ 

Notice: This attachment will be withheld  from public inspection in acco rdance with  23 Pa.C.S.  §6108(a)(7)(v). 
ﯿﺒﻨﺗ: 
ﮫ

.23 Pa.C.S. §6108(a)(7)(v)
 

 رﺎﻈﻧأ
 
ﻦﻋ ﻖﺤﻠﻤﻟا اﺬھ ﺐﺠﺣ ﻢﺘﯿﺳ

ةدﺎﻤﻠﻟ ًﺎﻘﺒط ﺔﻣﺎﻌﻟا
 

ENGLISH/ARABIC  PFA Pet. Attachment A 
Pa. R.C.P. 1905(b) Rev. 3-19 

 
2 

AOPC Rev. 4-2019