DOMESTIC VIOLENCE
AFFIDAVIT 

Vs.

_______________________________________ 
(Party name as displayed in case caption)  

______________________________ 
Docket/Case No. 

_______________________________________ 
(Party name as displayed in case caption)  

______________________________ 
Court 

Pursuant to Pa.R.Civ.P.M.D.J. 514.1:

1) I am a victim of domestic violence.

I, _________________________________, the undersigned, certify and declare as follows:

2) The name of the perpetrator of domestic violence: ____________________________

3) The perpetrator’s relationship to me is: _____________________________________

4) Docket number(s) (if applicable) of any protection from abuse case involving me and

the perpetrator:

_____________________________________________

_____________________________________________

I verify that the statements herein are true and correct.  I understand that false 
statements herein are made subject to the penalties of Section 4904 of the Crimes 
Code (18 Pa.C.S. § 4904) relating to unsworn falsification to authorities.

I certify that this filing complies with the provisions of the Case Records Public Access 
Policy of the Unified Judicial System of Pennsylvania that require filing confidential 
information and documents differently than non-confidential information or documents.

_________________________________ 

________________ 

Signature  

Date 

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Supplemental Instructions

A victim of domestic violence is "a person who has obtained a protection from abuse 
order against another individual or can provide other evidence of abuse."  See 
Pa.R.Civ.P.M.D.J. 1001(10); 68 P.S. 250.513.  A tenant who is aggrieved by a judgment 
for the delivery of real property arising out of a residential lease and who is a victim of 
domestic violence may appeal the judgment within 30 days after the date of the entry of 
judgment by filing a notice of appeal with the prothonotary/clerk of court of the court of 
common pleas, civil division, along with a copy of the Domestic Violence Affidavit.  A 
tenant who is a victim of domestic violence may file the Affidavit with the magisterial 
district court to stay the execution of an order for possession pursuant to Rule 514.1 prior 
to filing an appeal with the court of common pleas.  If the Affidavit is filed with the 
magisterial district court, the tenant should attach a copy of the Affidavit to the notice of 
appeal.  If the tenant does not file the Domestic Violence Affidavit with the magisterial 
district court or does not appeal to the court of common pleas within 21 days following the 
entry of the judgment, the tenant is at risk of eviction.

This Domestic Violence Affidavit is not a public record and it shall not be publically 
accessible.

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