COMMONWEALTH OF PENNSYLVANIA 
COUNTY OF

Mag. Dist. No:

MDJ Name:

Address:

Telephone:

PETITION FOR EMERGENCY 
RELIEF FROM ABUSE

PLAINTIFF:

NAME and ADDRESS

DEFENDANT:

V.

NAME and ADDRESS

Docket No:

Case Filed:

PLAINTIFF REQUESTS CONFIDENTIALITY 
OF PERMANENT/TEMPORARY ADDRESS

PETITION OF THE PLAINTIFF

I, ______________________________________________, hereby petition for emergency relief from abuse

(Name of Plaintiff - please print)

On behalf of myself.

On behalf of the following minor (child) (children) of whom I am a (parent) (adult household member) (guardian).

On behalf of the following incapacitated person to whom I am guardian.

(Name)

(Name)

The cause for seeking relief is as follows:

(Address)

(Address)

(Age)

(Age)

from  abuse 

Emergency  relief 
defendant to me and to the above listed minor (child) (children) (incapacitated person).
(Print additional names/addresses on a separate sheet of paper and attach hereto.)
Has Defendant been determined to be a perpetrator in a founded or indicated report under the Child Protective 
Services Law, 23 Pa.C.S. §§ 6301 - 6386?          

is  required  because 

there 

YES

NO

is 

immediate  and  present  danger  of  abuse  by 

the 

If  you  answered  Yes,  what  county's  court  or  child  protective  services  agency 
report? _______________________________________________________

issued  the  founded  or 

indicated 

MDJS 307A-BL

1

FREE INTERPRETER
www.pacourts.us/language-rights

COMMONWEALTH OF PENNSYLVANIA 
COUNTY OF

Mag. Dist. No:

MDJ Name:

Address:

Telephone:

PETITION FOR EMERGENCY 
RELIEF FROM ABUSE

PLAINTIFF:

NAME and ADDRESS

DEFENDANT:

V.

NAME and ADDRESS

Docket No:

Case Filed:

PLAINTIFF REQUESTS CONFIDENTIALITY 
OF PERMANENT/TEMPORARY ADDRESS

(Signature of the Plaintiff)

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 and 
documents.

MDJS 307A-BL

2

FREE INTERPRETER
www.pacourts.us/language-rights