Here is the text we could read:
_______________________________
Docket/Case No.
Nimewo Lis Dosye/Ka.
_______________________________
Court
Tribinal
_____________________________________
(Party name as displayed in case caption)
(Non pati a jan li afiche nan antèt ka a)
Vs./Kont
____________________________________
(Party name as displayed in case caption)
(Non pati a jan li afiche nan antèt ka a)
_
Pursuant to Pa.R.C.P.M.D.J. No. 514.1:
I, ______________________________, the
Selon Pa.R.C.P.M.D.J. Nimewo 514.1:
Mwen, ______________________________,
undersigned, certify and declare as follows:
moun ki siyen anba a, sètifye epi fè
deklarasyon sa a:
1)
I am a victim of domestic violence.
1) Mwen se viktim vyolans domestik.
2) The name of the perpetrator of domestic
2) Non moun ki fè vyolans domestik la:
violence: __________________________
__________________________
3) The perpetrator’s relationship to me is:
3) Sa moun ki fè vyolans domestik la ye
__________________________________
pou mwen: __________________________
4) Docket number(s) (if applicable) of any
4) Nimewo lis dosye a(yo) (si aplikab) pou
protection from abuse case involving me
nenpòt ka pwoteksyon kont abi ki enplike
and the perpetrator:
mwen ak moun ki fè vyolans lan:
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
Mwen verifye deklarasyon nan dokiman sa a
se verite epi yo kòrèk. Mwen konprann fo
deklarasyon mwen fè nan dokiman sa a ap
genyen penalite Seksyon 4904 nan Kòd Krim
lan (18 Pa. C.S. § 4904) ki gen rapò ak bay
otorite yo fo deklarasyon ki pa fèt sou sèman.
Mwen sètifye demann mwen depoze sa a
konfòme ak dispozisyon Politik Aksè Piblik nan
Dosye Ka Sistèm Jidisyè Inifye Pennsylvania a
ki egzije yo depoze enfòmasyon konfidansyèl
1
DOMESTIC VIOLENCE
AFFIDAVIT
AFIDAVID
VYOLANS DOMESTIK
information and documents differently than
non-confidential information or documents.
yon fason diferan ak fason yo depoze dokiman
ak enfòmasyon ki pa konfidansyèl yo.
______________________________________ ___________________________
Signature/Siyati: Date/Dat:
Supplemental Instructions
Enstriksyon Siplemantè
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.C.P.M.D.J. No. 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.
Yon viktim vyolans domestik se "yon moun ki
te jwenn yon òdonans pou pwoteksyon kont
abi kont yon lòt moun oswa yon moun ki
kapab bay lòt prèv ki montre gen abi." Gade
Pa.R.C.P.M.D.J. Nimewo 1001(10); 68 P.S.
250.513. Yon lokatè yon jijman pou remèt
yon byen imobilye ki soti nan yon kontra
lwaye rezidansyèl fè mal epi ki se viktim
vyolans domestik ka konteste jijman an nan
espas 30 jou apre dat antre jijman an nan
depoze yon avi pou apèl jiridik bòkote
pwotonotè a/grefye nan tribinal defans an
komen an, divizyon sivil, ansanm avèk yon
kopi Afidavid Vyolans Domestik la. Yon
lokatè ki se viktim vyolans domestik ka
depoze yon Afidavid nan tribinal distri
majistral la pou li ajoune egzekisyon yon
òdonans pou posesyon selon Règ 514.1
anvan li depoze yon apèl jiridik nan tribinal
defans an komen an. Si li depoze Afidavid la
nan tribinal distri majistral la, lokatè a ta dwe
atache yon kopi Afidavid la nan avi pou apèl
jiridik la. Si lokatè a pa depoze Afidavid
Vyolans Domestik la nan tribinal distri
majistral la oswa li pa konteste nan tribinal
defans an komen an nan espas 21 jou apre
antre jijman an, lokatè a gen risk pou yo
degèpi li.
This Domestic Violence Affidavit is not a
public record and it shall not be publicly
accessible.
Afidavid Vyolans Domestik sa a pa yon
dosye piblik epi li pa dwe aksesib pou piblik
la.
2
_
Haitian Creole Domestic Violence Affidavit
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): 2
- Fields(s): 13
- Average fields per page: 6
- Reading Level: Grade 13
- LIST Grouping(s):
GO-00-00-00-00.
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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.
party_name_displayed_case__1
was Party name as displayed in case caption (0.58 conf)party_name_displayed_case__2
was Party name as displayed in case caption_2 (0.33 conf)docket_case
was DocketCase No (0.35 conf)court
was Court (0.45 conf)tenant_name__1
was Tenant Name (0.47 conf)tenant_name__2
was Tenant Name_T (0.46 conf)perpetrator__1
was Perpetrator (0.44 conf)perpetrator_relationship__1
was Perpetrator Relationship (0.44 conf)perpetrator_relationship__2
was Perpetrator Relationship_T (0.38 conf)perpetrator__2
was Perpetrator_T (0.34 conf)perpetrator_docket_number__1
was Perpetrator Docket Number1 (0.38 conf)perpetrator_docket_number__2
was Perpetrator Docket Number1_T (0.38 conf)date_signedby_declarant
was DateSignedbyDeclarant (0.50 conf)
We've done our best to group similar variables togther to avoid overwhelming the user.
Suggested Screen 0:
party_name_displayed_case__1
party_name_displayed_case__2
Suggested Screen 1:
Suggested Screen 2:
Suggested Screen 3:
tenant_name__1
tenant_name__2
Suggested Screen 4:
perpetrator__1
perpetrator_relationship__1
perpetrator_relationship__2
perpetrator__2
Suggested Screen 5:
perpetrator_docket_number__1
perpetrator_docket_number__2
Suggested Screen 6:
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