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Here is the text we could read:

IN THE COURT OF COMMON PLEAS OF ______________ COUNTY 

AU TRIBUNAL DE PREMIÈRE INSTANCE DU COMTÉ DE ____________________ 

LAINTIFF / PARTIE DEMANDERESSE 

CASE NO. / AFFAIRE NO. __________________ 

___________________________ 

VS. 

DEFENDANT / PARTIE DÉFENDERESSE 

PROTECTION  FROM  ABUSE  /  PROTECTION 

CONTRE LES MAUVAIS TRAITEMENTS 

___________________________ 

PETITION FOR PROTECTION OF VICTIMS 
OF  

REQUÊTE DE PROTECTION DES VICTIMES 
DE  

  SEXUAL VIOLENCE 
  SEXUAL VIOLENCE AGAINST A 

  VIOLENCE SEXUELLE 
  VIOLENCE SEXUELLE CONTRE UN 

Plaintiff: 

1. 
__________________________________ 
First 

Last Name 

Middle  

 

 

laintiff’s Address:  

__________________________________ 
 

   Plaintiff’s  address  is  confidential  pursuant 

to 42 Pa.C.S. § 62A11. 

 

__________________________________ 
Prénom   Second prénom 
 
Adresse du Demandeur :  
__________________________________ 
 

 Nom de famille

 

 

  

L'adresse 

est 
confidentielle,  conformément  à  42  Pa.C.S.  § 
62A11. 

du  Demandeur 

MINEUR 
INTIMIDATION  

 

Demandeur : 

. 

  1

 

MINOR CHILD 
INTIMIDATION 

 

laintiff’s Date of Birth:  

ate de naissance du Demandeur : 

__________________________________ 

__________________________________ 

 am filing this petition on behalf of  

e dépose cette requête pour  

 myself or 

 another person. 

 moi-même ou 

 une autre personne. 

If you checked “myself,” please answer all 
questions referring to yourself as “Plaintiff.”  If 
you checked “another person,” please answer 

Si vous avez coché « moi-même », veuillez 
répondre à toutes les questions à votre sujet 
en tant que « Demandeur ». Si vous avez 

AOPC PSVI (French) 

Created: December 26, 2016 

 

 

 

 
 

  D

      J

  P

 

 

 

 

 
 

  P

    P

      I

all questions referring to that person as 
“Plaintiff,” and provide your name and address 
below. 

coché « une autre personne », veuillez 
répondre à toutes les questions concernant 
cette dernière en tant que « Demandeur » et 
indiquer ci-dessous votre nom et adresse. 

ame: ____________________________ 

om : ____________________________ 

ddress: __________________________ 

dresse : _________________________ 

f you checked “another person,” indicate your 
relationship to the plaintiff: 

i  vous  avez  coché  « une  autre  personne », 

indiquez votre relation avec le demandeur : 

_________________________________ 

_________________________________ 

. 

Defendant: 

. 

Défendeur : 

_______________________________ 
Last Name 

Middle   

First 

 

___________________________________ 
 Nom de famille 

Prénom     Second prénom 

efendant’s Address: 

dresse du Défendeur :  

________________________________ 
________________________________ 

________________________________ 
________________________________ 

DEFENDANT IDENTIFIERS 

IDENTIFIANTS DU DÉFENDEUR 

HEIGHT 

WEIGHT 

EYES 

DOB 

SEX 
RACE 

HAIR 

SSN 

DRIVERS 
LICENSE # 

 

 

 

 

 

 

 

EXP DATE 

STATE 

 

 

 

 

DATE DE 
NAISSANCE 

SEXE 

RACE 

CHEVEUX 
No SS 
NO DE 
PERMIS DE  
CONDUIRE  

DATE 
D'EXPIRATION 

 

 
 
 
 
 

 

TAILLE 

POIDS 
YEUX 

ÉTAT 

 

 
 

 

. 

Name(s) of other designated person(s) 

under 42 Pa.C.S. § 62A07(b)(1): 

____________________________________
_____________________________________ 

. 

Nom(s)  de 

la  ou  des  personnes 
désignées  conformément  à  42  Pa.C.S.  § 
62A07(b)(1) : 
_____________________________________
_____________________________________ 

AOPC PSVI (French) 

Created: December 26, 2016 

  N

  A

    S

  _

    2

  _

    A

   

    3

 
 

    N

  A

    I

  _

    2

  _

    D

   

    3

  _

  4

    5

    6

  S

    7

  D

  H

  L

.  

Is there a relationship between Plaintiff 
and Defendant? ________.   If yes, what is the 
relationship? 

____________________________________
_____________________________________ 

.  

Existe t-il une relation entre le 
Demandeur et le Défendeur ? ________. Le 
cas échéant, quelle est la nature de cette 
relation ? 
_____________________________________
_____________________________________ 

.  

Have Plaintiff and Defendant been 

.  

Le Demandeur et le Défendeur ont-ils 

involved in any other legal proceedings?  If so, 
state when and where the case was filed and 
the court docket number, if known:  

____________________________________
_____________________________________ 
_____________________________________
_____________________________________ 

été impliqués dans d'autres procédures 
judiciaires ? Le cas échéant, veuillez indiquer 
la date et le lieu d'enregistrement de l'affaire et 
le numéro de l'affaire, si vous les connaissez :  
_____________________________________
_____________________________________ 
_____________________________________
_____________________________________ 

.  

Has Defendant been involved in any 

.  

Le Défendeur a-t-il(elle) été partie à 

criminal proceedings?  
_____________________________________
_____________________________________ 

toute autre procédure pénale ?  
_____________________________________
_____________________________________ 

f you answered Yes, is Defendant currently on 
probation or parole?  

____________________________________
_____________________________________ 

i la réponse est oui, le Défendeur est-il(elle) 

à l'heure actuelle en liberté surveillée ou 
conditionnelle ?  
_____________________________________
_____________________________________ 

.  

(a) 

The facts of the most recent 
incident of sexual violence are as follows:  

.  

(a) 

Les faits liés à l'incident le plus 
récent de violence sexuelle sont les suivants :  

pproximate Date: 

ate approximative : 

__________________________________ 

__________________________________ 

pproximate Time: 

eure approximative : 

__________________________________ 

__________________________________ 

lace: 

__________________________________ 

__________________________________ 

AOPC PSVI (French) 

Created: December 26, 2016 

ieu : 

 
 

  4

  _

    5

  _

    6

  I

  _

    7

  A

  A

  P

  D

     

  D

  H

  L

    D

       

 
 

escribe 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):  

____________________________________
_____________________________________ 
_____________________________________
_____________________________________ 
_____________________________________
_____________________________________ 

écrivez en détail ce qui s'est passé, 
notamment tout acte constituant une 
maltraitance physique ou sexuelle, des 
menaces, une blessure, un harcèlement 
répété, tout traitement médical sollicité et/ou 
les appels aux forces de l'ordre (joindre des 
feuilles supplémentaires si nécessaire) :  
_____________________________________
_____________________________________ 
_____________________________________
_____________________________________ 
_____________________________________
_____________________________________ 

(b) 

The facts of the most recent 

(b) 

Les faits liés à l'incident le plus 

incident of intimidation are as follows: 

récent d'intimidation sont les suivants : 

pproximate Date: 

ate approximative : 

__________________________________ 

__________________________________ 

pproximate Time: 

eure approximative : 

__________________________________ 

__________________________________ 

lace: 

ieu : 

__________________________________ 

__________________________________ 

escribe in detail what happened, including 
medical treatment sought, and/or calls to law 
enforcement (attach additional sheets of paper 
if necessary):  
_____________________________________
_____________________________________ 
_____________________________________
_____________________________________ 
_____________________________________
_____________________________________ 

écrivez en détail ce qui s'est passé, 

notamment tout traitement médical sollicité 
et/ou les appels aux forces de l'ordre (joindre 
des feuilles supplémentaires si nécessaire) :  
_____________________________________
_____________________________________ 
_____________________________________
_____________________________________ 
_____________________________________
_____________________________________ 

  D

    _

     

  A

  A

  P

    D

       

AOPC PSVI (French) 

Created: December 26, 2016 

 If Defendant has committed prior acts 

8. 
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):  
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________ 

 Si le Défendeur a déjà commis à 

8. 
l'encontre du Demandeur des actes 
constituant une violence sexuelle ou une 
intimidation, décrivez ces incidents et indiquez 
la date approximative de ces incidents (joindre 
des feuilles supplémentaires si nécessaire) :  
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________ 

Identify the sheriff, police department, 

Indiquez le nom du shérif, du 

or other law enforcement agency in the area in 
which Plaintiff lives that should be provided 
with a copy of the protection order:  

____________________________________
_____________________________________ 

commissariat de police ou de tout autre 
organisme d’application de la loi situés à 
proximité du lieu de résidence du Demandeur 
auquel il faudra fournir un exemplaire de 
l'ordonnance de protection : 
_____________________________________
_____________________________________ 

0.  

Is Plaintiff in immediate and present 

danger from Defendant?  If so, please 
describe: 
_____________________________________
_____________________________________ 

0.  

Le Demandeur fait-il face à un danger 
immédiat et présent ? Le cas échéant, veuillez 
décrire ces actes : 
_____________________________________
_____________________________________ 

OR 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):  

OUR LES RAISONS INDIQUÉES CI-
DESSUS, JE DEMANDE À CE QUE LE 
TRIBUNAL RENDE UNE ORDONNANCE 
PROVISOIRE ET, SUITE À UNE AUDIENCE, 
UNE ORDONNANCE DÉFINITIVE 
COMPRENANT LES REDRESSEMENTS 
SUIVANTS (COCHEZ TOUTES LES 
FORMES DE REDRESSEMENT 
DEMANDÉES) :  
 

 A.  Restrain Defendant from having any 

 A.  Empêcher le Défendeur d'entrer en 

contact with the victim, including, but not 
limited to, entering the victim’s residence, 
place of employment, business, or school.  
 

contact avec la victime, y compris, sans 
toutefois s'y limiter, pénétrer dans le lieu de 
résidence, de travail, l'entreprise ou 
l'établissement scolaire de la victime.  

.  

  9

    _

  1

  F

     

.  

  9

  1

  P

 
 

AOPC PSVI (French) 

Created: December 26, 2016 

 

   

   

   

 
 

 B.   Prohibit indirect contact through third 

 B.   Interdire tout contact indirect, par 

l'intermédiaire de tiers. 
 

 C.  Prohibit direct or indirect contact with 

 C. 

Interdire tout contact direct ou indirect 

other designated persons. 
 

avec d'autres personnes désignées. 
 

 D.   Order Defendant to pay the fees of this 

 D.   Ordonner au Défendeur de payer les 

 E.   Order the following additional relief, not 

 E.   Ordonner le redressement 

parties. 
 

action.  
 

listed above:  

frais relatifs à cette affaire.  
 

supplémentaire suivant, qui n'est pas indiqué 
ci-dessus : 
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________ 

____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________ 

 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.  

 F.   Accorder tout autre redressement que 

le tribunal juge approprié, y compris sans 
toutefois s'y limiter, rendre une ordonnance 
conformément à 42 Pa.C.S. § 62A11(b) liée à 
la non-divulgation de l'adresse, du numéro de 
téléphone de la victime, du lieu où elle se 
trouve ou toutes autres données 
démographiques concernant la victime.  

 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.   Ordonner à la police, au shérif ou à 
tout autre organisme d’application de la loi de 
signifier au Défendeur un exemplaire de cette 
requête, de toute ordonnance rendue et de 
l'avis d'audience. Le Demandeur informera 
l'autorité désignée des adresses, autres que 
celle du lieu de résidence du Défendeur, où 
ces documents pourront être signifiés au 
Défendeur.  

 

   

     

       

  _

AOPC PSVI (French) 

Created: December 26, 2016 

VERIFICATION 

ATTESTATION 

J'atteste que les déclarations faites 
dans le cadre de la présente requête sont, 
pour autant que je le sache, exactes et 
correctes. Je comprends que toute déclaration 
mensongère faite aux présentes peut donner 
lieu à des sanctions, conformément à 18 
Pa.C.S. § 4904, ayant trait à une fausse 
déclaration aux autorités. 
 

   

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 / Signature 

Date / Date 
 

 

AOPC PSVI (French) 

Created: December 26, 2016

French Notice of Hearing and Order, Petition, Temporary Order, Affidavit of Service and the Final Order

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Pennsylvania state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.pacourts.us (2023-03)
Page(s): 7
Fields(s): 169
Average fields per page: 24
Reading Level: Grade 12
LIST Grouping(s): GO-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

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count was COUNTY_2 (0.37 conf)
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undefined__3 was undefined_6 (0.39 conf)
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plaintiffs_address was Plaintiffs Address (0.42 conf)
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plaintiffs_date_birth was Plaintiffs Date of Birth (0.44 conf)
date_de_naissance_du_demandeur was Date de naissance du Demandeur (0.53 conf)
check_box__1 was Check Box3 (0.37 conf)
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cheveux was CHEVEUX (0.35 conf)
driver_license was DRIVERS LICENSE (0.46 conf)
ss was No SS (0.47 conf)
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approximate_date__2 was Approximate Date_2 (0.36 conf)
date_approximative__2 was Date approximative_2 (0.33 conf)
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1_4 was 1_4 (0.38 conf)
2_4 was 2_4 (0.38 conf)
lordonnance_de_protection__1 was lordonnance de protection 1 (0.43 conf)
lordonnance_de_protection__2 was lordonnance de protection 2 (0.43 conf)
describe__1 was describe 1 (0.45 conf)
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date was Date Date_2 (0.41 conf)
text was Text29 (0.35 conf)

We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

French Notice of Hearing and Order, Petition, Temporary Order, Affidavit of Service and the Final Order

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02