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

 

1)  This affidavit is made pursuant to the 
Servicemembers Civil Relief Act (50 
U.S.C. § 3931). 
I am the plaintiff in the above-captioned 
matter. 

2) 

Mwen, 
_______________________________________, 
moun ki siyen anba a, sètifye epi fè deklarasyon 
sa a: 
 

1)  Afidavid sa a fèt selon Lwa sou 

Reparasyon Sivil pou Militè yo (50 U.S.C. 
§ 3931). 

2)  Mwen se pleyan nan afè ki endike anwo 

a. 

3)  As of the current date: (check one) 

3)  Apati dat jodi a: (tcheke youn) 

  a.)  I have personal knowledge that 

the defendant named above is in 
military service. 

  a.)  Mwen gen konesans pèsonèl 
defandè ki endike anwo a nan 
sèvis militè. 

  b.)  I have personal knowledge that 

  b.)  Mwen gen konesans pèsonèl 

the defendant named above is not 
in military service. 

  c.)  I am unable to determine whether 
the defendant named above is in 
military service. 

4)  The following facts support the above 
statement (explain how you know the 
defendant is or is not in military service, 
or, if unable to make a determination, 
the steps you took to investigate the 
defendant’s military status): 

defandè ki endike anwo a pa nan 
sèvis militè. 

  c.)  Mwen pa kapab detèmine si 

defandè ki endike anwo a nan 
sèvis militè. 

4)  Fè sa yo kore deklarasyon anwo a 

(eksplike jan ou konnen defandè a ye 
oswa pa ye nan sèvis militè a, oswa, si 
w pa kapab fè yon detèminasyon, mezi 
ou te pran pou fè rechèch sou estati 
militè defandè a): 

 

 

   

(Party name as displayed in case caption) 
(Non pati a jan li afiche nan antèt ka a) 

Docket/Case No. 
Nimewo Lis Dosye/Ka. 

Vs. / Kont 

(Party name as displayed in case caption) 
(Non pati a jan li afiche nan antèt ka a) 

Court 
Tribinal 

SERVICEMEMBERS CIVIL RELIEF ACT 
AFFIDAVIT 

AFIDAVID LWA SOU REPARASYON SIVIL 
POU MILITÈ 

I verify that the statements herein are true and 
correct to the best of my knowledge, information 
and belief. I understand that false statements 
herein are made subject to the penalties of 

Mwen verifye deklarasyon nan dokiman sa a se 
verite epi yo kòrèk selon pi bon konesans, 

enfòmasyon ak kwayans mwen. Mwen 

konprann fo deklarasyon mwen fè nan dokiman 

   

 

   

 

           

Section 4904 of the Crimes Code (18 Pa. C.S. § 
4904) relating to unsworn falsification to 
authorities. 

 

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. 
 

I certify that this filing complies with the 

Mwen sètifye demann mwen depoze sa a 

provisions of the Case Records Public Access 
Policy of the Unified Judicial System of 

konfòme ak dispozisyon Politik Aksè Piblik nan 
Dosye Ka Sistèm Jidisyè Inifye Pennsylvania a 

Pennsylvania that require filing confidential 
information and documents differently than non-

ki egzije yo depoze enfòmasyon konfidansyèl 
yon fason diferan ak fason yo depoze dokiman 

confidential information or documents. 

ak enfòmasyon ki pa konfidansyèl yo. 

Signature / Siyati: 

NOTE:  For the definition of military service, see 50 
U.S.C. § 3911(2). 

REMAK:  Pou definisyon sèvis militè, gade 50 
U.S.C. § 3911(2). 

 
The Servicemembers Civil Relief Act website 

 
Sitwèb Lwa sou Reparasyon Sivil pou Militè yo 

(https://scra.dmdc.osd.mil) is a website maintained 
by the Department of Defense that may be used to 

(https://scra.dmdc.osd.mil) se yon sitwèb Depatman 
Defans ap jere ou ka itilize pou detèmine estati militè 

determine the defendant’s military status. 

defandè a. 

 
See 50 U.S.C. § 3931(c) for additional penalties for 

 
Gade 50 U.S.C. § 3931(c) pou konnen penalite 

knowingly making or using a false affidavit. 

anplis ki genyen si ou fè ekspre ou fè oswa itilize yo 
fo afidavid.