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Here is the text we could read:

IN THE COURT OF COMMON PLEAS OF ______________ COUNTY 
ةعطاقمل ةماعلا ةيئادتبلاا ةمكحملا يف____________________ 
 

CASE NO. / ةيضقلا مقر __________________ 

LAINTIFF / يعدملا 

 
___________________________ 
 
                       VS.  
 
DEFENDANT / هيلع ىعدملا 
 
___________________________ 
 

PROTECTION FROM ABUSE / 
نم ةيامح 
ا
 
س
ا
ء
ة

 

 
PETITION FOR PROTECTION OF VICTIMS 
OF  

SEXUAL VIOLENCE 
SEXUAL VIOLENCE AGAINST A 

MINOR CHILD 

INTIMIDATION 

 

اياحض ةيامحل

 

سامتلا

 

 
يسنجلا فنعلا
 
رصاق لفط دض يسنجلا فنعلا
 

 

 

ءادتعلاا
 

Plaintiff: 

1. 
_____________________________________________________________________ 

 

First 
 

Middle  

 

Last Name 

 

 

1.
______________________________________________________________________

:يعدملا
 

 

 

  

 

 

ريخلأا مسلاا
 

 

 

طسولأا
 

لولأا مسلاا
 

laintiff’s Address: ______________________________________________________ 
 
:يعدملا ناونع
 

 _____________________________________________________________

 

 

 

 

 

 

 

   

 

 

  P

 
 

 

  P

         

 

  Plaintiff’s address is confidential pursuant to 42 Pa.C.S. § 62A11. 

 

 

.نوناقلا نم
 
42 Pa.C.S. § 62A11

 

ةرقفلل

 اًقبط يرس يعدملا ناونع نإ
 

   

 
 :يعدملا دلايم خيرات

laintiff’s Date of Birth: _______________________________________________ 

 

 _________________________________________________________

 myself 

 another person. 

I am filing this petition on behalf of 
or 
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. 

 صخش

 

 وأ يسفن
 

 نع ةباين ةضيرعلا هذه لأمأ ينإ
.رخآ
 ةلئسلأا لك نع ةباجلإا ىجرُي "يسفن" ىلع ترشأ اذإ
 ىلع ترشأ اذإ ."يعدملا" كتفصب كسفن ىلإ ريشت يتلا
 ريشت يتلا ةلئسلأا لك نع ةباجلإا ىجرُي ،"رخآ صخش"
 كمسا ريفوتو "يعدملا" هتفصب صخشلا
 كلذ ىلإ
.هاندأ كناونعو

 

 

ame: __________________________________________________________ 

 

 __________________________________________________________

:مسلاا

ddress: _________________________________________________________ 

 

 _________________________________________________________

 :نا

 
ونعلا
 

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

____________________________________________________________________ 

_____________________________________________________________________
 

 

:يعدملاب

 كتقلاع نّيب ،"رخآ صخش" ىلع ترشأ اذإ

 

 

    P

  N

 

  A

  I

  _

 

 
 

             

 

Defendant: 

هيلع:
 

يعدملا .

2

_______________________________ 

First 

    Middle  

   Last Name 

_______________________________ 
لولأا مسلاا
 
 

ريخلأا مسلاا
 

طسولأا
 

 

Defendant’s Address:  
________________________________ 
________________________________ 
 

 

:هيلع يعدملا ناونع
________________________________ 
________________________________ 
 

 

 

 دلايملا خيرات   
 
 عونلا  
 
 
 قرعلا  
 
 
 رعشلا  
 
 
 

DOB
SEX
RACE
HAIR
SSN نامضلا مقر
يعامتجلاا 
DRIVERS 
LICENSE # 
 ةدايقلا ةصخر 

 

EXP DATE
ءاهتنلاا 

 خيرات
 

 

DEFENDANT IDENTIFIERS هيلع ىعدملا تافرعم 
 
HEIGHT
WEIGHT
EYES

 لوطلا   
 
نزولا   
 
 نانيعلا  
 
 

 

STATE

 

ةيلاولا

 

   

3. 

Name(s) of other designated person(s) under 42 Pa.C.S. § 62A07(b)(1): 

___________________________________________________________________ 

 

:نوناقلا نم
 

42 Pa.C.S. § 62A07(b)(1)

 ةرقفلا بجومب نينيعملا نيرخلآا صاخشلأا )ءامسأ( مسا

 

3.

___________________________________________________________________ 

 

.  

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

is the relationship? 
_____________________________________________________________________ 

 

؟ةقلاعلا يه ام ،معن ةباجلإا تناك اذإ .

________ 
4. 
_____________________________________________________________________ 
 

؟هيلع ىعدملاو يعدملا نيب ةقلاع

يأ كانه له
 

 

 

 

2. 
 

  _

  _

  _

 

  _

  4

   

             

 

     

 

:يسنج فنع ثداح رخآ عئاقو يلي اميف
 

 )أ(

7. 

Have Plaintiff and Defendant been involved in any other legal proceedings?  If 
5.  
so, state when and where the case was filed and the court docket number, if known:  
_____________________________________________________________________ 
_____________________________________________________________________ 
 
 امو ةيضق عفر مت نيأو ىتم ،كلذك رملأا ناك اذإ ؟ىرخأ ةينوناق

5. 
:اًمولعم ناك نإ ةمكحملا عئاقو مقر وه
_____________________________________________________________________ 
_____________________________________________________________________ 
 

 تاءارجإ يأ يف هيلع ىعدملاو يعدملا كرتشا له

 

 

Has Defendant been involved in any criminal proceedings?  

______________________________________________________________________ 
 

6 .
______________________________________________________________________ 
 

؟ةيئانج تاءارجإ يأ يف هيلع ىعدملا كرتشا له

 

 

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

 هيلع ىعدملا له ،معن ةباجلإا تناك اذإ
_____________________________________________________________________ 
 

اًيلاح ةيئاضقلا ةبقارملا تحت

؟طورشم حارس قلاطإ وأ

 

 

.  

(a) 

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

pproximate Date: ______________________________________________________ 

pproximate Time: ______________________________________________________ 

lace: ________________________________________________________________ 

___________________________________________________________

 :يبيرقتلا خيراتلا

 ____________________________________________________________

:يبيرقتلا

 تقولا

 ________________________________________________________________

 :ناكملا

 

 

  I

  7

  A

  A

  P

 
 
 

   

   

 

.  

  6

 

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):  
______________________________________________________________________ 
______________________________________________________________________ 
______________________________________________________________________ 
 

 سامتلا وأ ،ةسلخ بقعتلا وأ ،حورجلا وأ ،تاديدهتلا وأ ،

 
 كلذ يف امب ،ثدح ام ليصفتلاب ف ِص
 وأ/و ،يبطلا جلاعلا
______________________________________________________________________ 
______________________________________________________________________ 
______________________________________________________________________ 

:)رملأا مزل نإ قارولأا نم ةيفاضإ تاحفص قفرأ( نوناقلا

 تاطلسب تلااصتلاا

يدسجلا
 

 
قيبطت

ة
يسنجلا وأ

ةءاسلإا

ة 

 

(b) 

The facts of the most recent incident of intimidation are as follows: 

pproximate Date: ______________________________________________________ 

pproximate Time: ______________________________________________________ 

lace: ________________________________________________________________ 

___________________________________________________________

 

:ءادتعا ثداح رخآ عئاقو يلي اميف

 
)ب(
 :يبيرقتلا خيراتلا

 ____________________________________________________________

:يبيرقتلا تقولا

 

 ________________________________________________________________

 :ناكملا
 

escribe in detail what happened, including medical treatment sought, and/or calls to 

law enforcement (attach additional sheets of paper if necessary):  
______________________________________________________________________ 
______________________________________________________________________ 
______________________________________________________________________ 
 
 ةيفاضإ تاحفص قفرأ( نوناقلا

لااصتلاا وأ/و ،يبطلا جلاعلا سامتلا كلذ يف امب ،ثدح ام ليصفتلاب ف ِص
:)رملأا مزل نإ قارولأا نم
______________________________________________________________________ 
______________________________________________________________________ 
______________________________________________________________________ 

 تاطلسب ت

قيبطت

 

 

 

 

     

  A

  A

  P

 

 
 

   

  D

 

 If Defendant has committed prior 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): 
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________ 
 
 نّيبو  ،ةقباسلا  ثادحلأا  هذه  ف ِص  ،يعدملا  دض

  لاعفأ
هيلع  ىعدملا  بكترا  اذإ    .
8
(
 ثادحلأا هذه تعقو ىتم بيرقتلاب
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
 

:)رملأا مزل نإ قارولأا نم ةيفاضإ تاحفص قفرأ

ءادتعا  وأ  ةقباس  يسنج  فنع  لامعأ

 

 

 

 

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: 
______________________________________________________________________ 
 

 يغبني يتلا يعدملا اهيف شيعي يتلا ةقطنملا يف نوناقلا

 ددح
فيرشلا
 
9. 
رمأ نم ةخسنب اهديوزت
______________________________________________________________________
 

 تلااكو نم هريغ وأ ،ةطرشلا مسق وأ ،
 

 
:ةيامحلا

قيبطت

 

 

0.  

Is Plaintiff in immediate and present danger from Defendant?  If so, please 

describe: 
______________________________________________________________________ 
 

10. 
______________________________________________________________________ 

:فصولا ىجرُي ،كلذك رملأا ناك نإ ؟هيلع ىعدملا بناج نم

 يف يعدملا

كيشو يلاح

 رطخ

 له
 

 

 

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):  
 

 

 نأ بلطأ ينإف ،هلاعأ ةنيبملا بابسلأل ا ًرظن
 نأو ،اًتقؤم ا ًرمأ ةمكحملا ردصت
 رمأ
 
 اًيئاهن
يلاتلا فاصنلإا
 
:)ةبولطملا
 
فاصنلإا

ردصت
 لك نمضتي عامتسلاا ةسلج دعب
 لك ىلع رشأ(
 لاكشأ
 

 A.  Restrain Defendant from having any 

 لاصتا يأب مايقلا نم هيلع ىعدملا

عنم 

  .أ

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

 ،رصحلا لا لاثملا لي
بس ىلع ،كلذ يف امب ،ةيحضلاب
 وأ ،هتكرش وأ ،هلمع ناكم وأ ،ةيحضلا نكس لوخد
 .هتسردم

 

 

 

. 

  8

.  

  9

  1

  F

 

 

 

 

 

                   

 

 
 فارطأ للاخ نم رشابملا ريغ لاصتلاا عنم .ب

 
.ةثلاث

 

 عم رشابملا ريغ وأ رشابملا لاصتلاا عنم .ج
 

.نينيعم نيرخآ صاخشأ

 

 B.   Prohibit indirect contact through third 

 C.  Prohibit direct or indirect contact with 

other designated persons. 
 

parties. 
 

action.  
 

 D.   Order Defendant to pay the fees of this 

 

.ءارجلإا اذه موسر عفدب هيلع ىعدملا رمأ .د

 

 E.   Order the following additional relief, not 

 ةيلاتلا

 

ةيفاضلإا فاصنلإا

listed above:  
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________ 
 

 

 تاءارجإب رملأا .ـه
:هلاعأ اهجاردإ متي مل يتلاو

 

 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.  
 

 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.  
 

 

 

 ةمكحملا اهربتعت يتلا

 تاءارجإ حنم .و

42 Pa.C.S. § 

فاصنلإا
 ،رصحلا لا لاثملا ليبس ىلع ،كلذ يف امب ،ةبسانم
 ةرقفلا بجومب رمأ رادصإ
 
62A11(b)
 وأ ،هدجاوت نكامأ وأ ،هفتاه مقر وأ ،ةيحضلا ناونع
 .ةيفارغوميدلا تامولعملا نم اهريغ

 ءاشفإ مدعب ةطبترملاو نوناقلا نم

 

 نم ةخسنب هيل

قيبطت

 نم امهريغ وأ ،

 وأ ،ةطرشلا رمأ .ز
 

فيرشلا
ع ىعدملا ميلستب نوناقلا

 
 تلااكو
 ةسلجل رمأ يأو ،ردصأ رمأ يأو ،ةضيرعلا هذه
 يأب ةصتخملا ةطلسلا ىعدملا غلبيس .عامتسلاا
 ميلست اهيف نكمي ،هيلع ىعدملا نكس ريغ ،نيوانع
.هيلع ىعدملا

 

 

 

 

VERIFICATION 

ديكأت 

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. 

 
 ةضيرعلا هذه يف ةمدقملا تانايبلا نأ دكؤأ ينإ

       
 ءلادلإا نأ مهفأ .يملع دح ىلع ةحيحصو ةيقيقح
18 
 
ينضرعت
ةفئاز تادافإب
Pa.C.S. § 4904
 ةبذاك تادافإ ميدقتب
 ةقلعتملا
 
.تاطلسلا ىلإ اهيلع موسقم ريغ

 نوناقلا تابوقعل

 انه

 

 

____________________________________________________________________ 

Signature / عيقوتلا 
_____________________________________________________________________ 
Date / خيراتلا 
 

 

 

  _

Arabic 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): 8
Fields(s): 114
Average fields per page: 14
Reading Level: Grade 13
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.

count was COUNTY_2 (0.52 conf)
n_th_e_cour_f_commo_plea was IN THE COURT OF COMMON PLEAS OF_2 (0.41 conf)
fill__1 was fill_4_3 (0.40 conf)
defendan was DEFENDANT_2 (0.32 conf)
fill__2 was fill_3_3 (0.40 conf)
unknown__1 was 1 (0.38 conf)
1_2 was 1_2 (0.38 conf)
undefined__1 was undefined (0.38 conf)
plaintiffs_address was Plaintiffs Address (0.42 conf)
check_box__1 was Check Box8 (0.37 conf)
check_box__2 was Check Box9 (0.37 conf)
check_box__3 was Check Box10 (0.37 conf)
check_box__4 was Check Box11 (0.37 conf)
check_box__5 was Check Box12 (0.37 conf)
check_box__6 was Check Box13 (0.37 conf)
undefined__2 was undefined_2 (0.39 conf)
plaintiffs_date_birth was Plaintiffs Date of Birth (0.44 conf)
address was address below (0.37 conf)
fill__3 was fill_4_4 (0.40 conf)
users1_address_line_one was Address (1.00 conf)
fill__4 was fill_6 (0.36 conf)
another_person_relationship was If you checked another person indicate your relationship to the plaintiff (0.47 conf)
fill__5 was fill_8 (0.36 conf)
check_box__7 was Check Box14 (0.37 conf)
check_box__8 was Check Box15 (0.37 conf)
check_box__9 was Check Box16 (0.37 conf)
check_box__10 was Check Box17 (0.37 conf)
check_box__11 was Check Box18 (0.37 conf)
check_box__12 was Check Box1 (0.52 conf)
undefined__3 was undefined_3 (0.39 conf)
first was First (0.34 conf)
defendants_address__1 was Defendants Address 1 (0.31 conf)
defendants_address__2 was Defendants Address 2 (0.31 conf)
fill__6 was fill_5 (0.36 conf)
fill__7 was fill_6_2 (0.40 conf)
fill__8 was fill_13 (0.36 conf)
fill__9 was fill_14 (0.36 conf)
fill__10 was fill_15 (0.36 conf)
fill__11 was fill_16 (0.36 conf)
fill__12 was fill_17 (0.36 conf)
fill__13 was fill_18 (0.36 conf)
fill__14 was fill_19 (0.36 conf)
fill__15 was fill_20 (0.36 conf)
fill__16 was fill_21 (0.36 conf)
fill__17 was fill_22 (0.36 conf)
fill__18 was fill_23 (0.36 conf)
unknown__2 was 3 (0.38 conf)
fill__19 was fill_8_2 (0.40 conf)
undefined__4 was undefined_4 (0.39 conf)
relationship was is the relationship (0.42 conf)
fill__20 was fill_11 (0.36 conf)
unknown__3 was 4 (0.38 conf)
state_case_filed_court_number__1 was so state when and where the case was filed and the court docket number if known 1 (0.43 conf)
state_case_filed_court_number__2 was so state when and where the case was filed and the court docket number if known 2 (0.43 conf)
fill__21 was fill_3_4 (0.40 conf)
fill__22 was fill_4_5 (0.40 conf)
unknown__4 was 6 (0.38 conf)
undefined__5 was undefined_5 (0.39 conf)
defendant_probation_parole was If you answered Yes is Defendant currently on probation or parole (0.44 conf)
fill__23 was fill_8_3 (0.40 conf)
facts_sexual_follows__1 was The facts of the most recent incident of sexual violence are as follows 1 (0.39 conf)
facts_sexual_follows__2 was The facts of the most recent incident of sexual violence are as follows 2 (0.39 conf)
approximate_time__1 was Approximate Time (0.34 conf)
fill__24 was fill_12 (0.36 conf)
fill__25 was fill_13_2 (0.40 conf)
fill__26 was fill_14_2 (0.40 conf)
additional_sheets_paper__1 was attach additional sheets of paper if necessary 1 (0.36 conf)
additional_sheets_paper__2 was attach additional sheets of paper if necessary 2 (0.36 conf)
additional_sheets_paper__3 was attach additional sheets of paper if necessary 3 (0.36 conf)
fill__27 was fill_4_6 (0.40 conf)
fill__28 was fill_5_2 (0.40 conf)
fill__29 was fill_6_3 (0.40 conf)
facts_incident_follows__1 was The facts of the most recent incident of intimidation are as follows 1 (0.33 conf)
facts_incident_follows__2 was The facts of the most recent incident of intimidation are as follows 2 (0.33 conf)
approximate_time__2 was Approximate Time_2 (0.30 conf)
fill__30 was fill_10 (0.36 conf)
fill__31 was fill_11_2 (0.40 conf)
fill__32 was fill_12_2 (0.40 conf)
additional_sheets_paper__4 was law enforcement attach additional sheets of paper if necessary 1 (0.49 conf)
additional_sheets_paper__5 was law enforcement attach additional sheets of paper if necessary 2 (0.49 conf)
additional_sheets_paper__6 was law enforcement attach additional sheets of paper if necessary 3 (0.49 conf)
fill__33 was fill_16_2 (0.40 conf)
fill__34 was fill_17_2 (0.40 conf)
fill__35 was fill_18_2 (0.40 conf)
additional_sheets_paper__7 was occurred attach additional sheets of paper if necessary 1 (0.37 conf)
additional_sheets_paper__8 was occurred attach additional sheets of paper if necessary 2 (0.37 conf)
additional_sheets_paper__9 was occurred attach additional sheets of paper if necessary 3 (0.37 conf)
fill__36 was fill_4_7 (0.40 conf)
fill__37 was fill_5_3 (0.40 conf)
fill__38 was fill_6_4 (0.40 conf)
area_plaintiff_provided was area in which Plaintiff lives that should be provided with a copy of the protection order (0.39 conf)
fill__39 was fill_8_4 (0.40 conf)
describe was describe (0.40 conf)
fill__40 was fill_10_2 (0.40 conf)
check_box__13 was Check Box19 (0.37 conf)
check_box__14 was Check Box20 (0.37 conf)
listed__1 was listed above 1 (0.40 conf)
listed__2 was listed above 2 (0.40 conf)
listed__3 was listed above 3 (0.40 conf)
listed__4 was listed above 4 (0.40 conf)
check_box__15 was Check Box21 (0.37 conf)
check_box__16 was Check Box22 (0.37 conf)
check_box__17 was Check Box23 (0.37 conf)
check_box__18 was Check Box24 (0.37 conf)
check_box__19 was Check Box25 (0.37 conf)
check_box__20 was Check Box26 (0.37 conf)
check_box__21 was Check Box27 (0.37 conf)
check_box__22 was Check Box28 (0.37 conf)
check_box__23 was Check Box29 (0.37 conf)
check_box__24 was Check Box30 (0.37 conf)
check_box__25 was Check Box31 (0.37 conf)
check_box__26 was Check Box32 (0.37 conf)
text__1 was Text33 (0.35 conf)
text__2 was Text34 (0.35 conf)

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

Arabic 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