§ Rule 1905 Forms For Use in PFA Actions Notice and Hearing Petition Temporary Protection Order Final Protection Order

Rule 1905. Forms For Use in PFA Actions. Notice and Hearing. Petition. Temporary Protection Order. Final Protection Order

(a) The Notice of Hearing and Order required by Rule 1901.3 shall be substantially in the following form:

(Caption)

NOTICE OF HEARING AND ORDER

YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following papers, you must appear at the hearing scheduled herein. If you fail to do so, the case may proceed against you and a FINAL order may be entered against you granting the relief requested in the petition. In particular, you may be evicted from your residence, be prohibited from possessing any firearm, other weapon, ammunition or any firearm license, and lose other important rights, including custody of your children. Any protection order granted by a court may be considered in
subsequent proceedings under Title 23 (Domestic Relations) of the Pennsylvania Consolidated Statutes, including child custody proceedings under Chapter 53 (relating to custody).

A hearing on the matter is scheduled for the ___ day of __________, 20___, at ___.m. in Courtroom ___ at __________ Courthouse, __________, Pennsylvania.

If an order of protection has been entered, you MUST obey the order until it is modified or terminated by the court after notice and hearing. If you disobey this order, the police or sheriff may arrest you. Violation of this order may subject you to a charge of indirect criminal contempt which is punishable by a fine of up to $1,000 and/or up to six months in jail under 23 Pa.C.S.A. § 6114.Violation may also subject you to prosecution and criminal penalties under the Pennsylvania Crimes Code. Under federal law, 18 U.S.C. § 2265, this order is enforceable anywhere in the United States, tribal lands, U.S. Territories and the Commonwealth of Puerto Rico. If you travel outside of the state and intentionally violate this order, you may be subject to federal criminal proceedings under the Violence Against Women Act, 18 U.S.C. §§ 2261--2262.

If this order directs you to relinquish any firearm, other weapon, ammunition or any firearm license to the sheriff, you may do so upon service of this order. As an alternative, you may relinquish any firearm, other weapon, or ammunition listed herein to a third party provided you and the third party first comply with all requirements to obtain a safekeeping permit. 23 Pa.C.S.A. § 6108.3. You must relinquish any firearm, other weapon, ammunition or any firearm license listed in the order no later than 24 hours after service of the order. If, due to their current location, firearms, other
weapons or ammunition cannot reasonably be retrieved within the time for relinquishment, you must provide an ffidavit to the sheriff listing the firearms, other weapons or ammunition and their current location no later than 24 hours after service of the order. Failure to timely relinquish any firearm, other weapon, ammunition or any firearm license shall result in a violation of this order and may result in criminal conviction under the Uniform Firearms Act, 18 Pa.C.S.A. § 6105.

NOTICE: Even if this order does not direct you to relinquish firearms, you may be subject to federal firearms prohibitions and federal criminal penalties under 18 U.S.C. § 922(g)(8).

YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. YOU HAVE THE RIGHT TO HAVE A LAWYER REPRESENT YOU AT THE HEARING. THE COURT WILL NOT, HOWEVER, APPOINT A LAWYER FOR YOU. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. IF YOU CANNOT FIND A LAWYER, YOU MAY HAVE TO PROCEED WITHOUT ONE.

County Lawyer Referral Service

[insert Street Address]

[insert City, State, and ZIP]

[insert Phone Number]

(b) The petition in an action filed pursuant to the Act shall be substantially in the following form, but the first page (paragraphs 1 through 4), following the Notice of Hearing and Order, must be exactly as set forth in this rule:

PETITION FOR PROTECTION FROM ABUSE IN THE COURT OF COMMON PLEAS OF __________

COUNTY, PENNSYLVANIA NO.

1. PLAINTIFF

First Middle Last Plaintiff's DOB

Plaintiff's Address:

[ ] Plaintiff's address is confidential or [ ] Plaintiff's address is: _________________________

2. DEFENDANT

First Middle Last Suffix

Defendant's Address:

______________________________

DEFENDANT IDENTIFIERS

______________________________

DOB HEIGHT

SEX WEIGHT

RACE EYES

CAUTION: HAIR

[ ] Weapon Involved SSN

[ ] Weapon Present on the Property DRIVER'S

LICENSE #

[ ] Weapon Requested Relinquished EXP DATE STATE

Defendant's place of employment is: ______________________________

[ ] Check here if you have reason to believe that Defendant is a licensed firearms dealer; is employed by a licensed firearms dealer or manufacturer; is employed as a writer, researcher or technician in the firearms or hunting industry; or is required to carry a firearm as a condition of employment.

3. I am filing this Petition on behalf of: [ ] Myself and/or [ ] Another Person

If you checked “myself”, please answer all questions referring to yourself as “Plaintiff”. If you ONLY checked “another person”,please answer all questions referring to that person as the “Plaintiff”, and provide your name and address here, as filer, unless confidential.

Filer's Name:

First Middle Last Suffix

[ ] Filer's address is confidential or [ ] Filer's address is:

If you checked “Another Person”, indicate your relationship with Plaintiff:

[ ] parent of minor Plaintiff(s)

[ ] applicant for appointment as guardian ad litem of minor Plaintiff(s)

[ ] adult household member with minor Plaintiff(s)

[ ] court appointed guardian of incompetent Plaintiff(s)

4. Name(s) of all persons, including minor child/ren who seek protection from abuse:

5. Indicate the relationship between Plaintiff and Defendant.

CHECK ALL THAT APPLY:

[ ]spouse or former spouse of Defendant

[ ]parent of a child with Defendant

[ ]current or former sexual or intimate partner with Defendant

[ ]child of Plaintiff

[ ]child of Defendant

[ ]family member related by blood (consanguinity) to Defendant

[ ]family member related by marriage or affinity to Defendant

[ ]sibling (person who shares parenthood) of Defendant

[ ]Check here if Defendant is 17 years old or younger.

6. Have Plaintiff and Defendant been involved in any of the following court actions? [ ]Divorce [ ] Custody [ ] Support [ ] Protection From Abuse If you checked any of the above, briefly indicate when and where the case was filed and the court number, if known:

7. Has Defendant been involved in any criminal court action? _________________

If you answered Yes, is Defendant currently on probation? ____________________

8. Plaintiff and Defendant are the parents of the following minor child/ren:

Name(s) Age(s) who reside at (list address unless confidential)

_____________ ___________ ___________________________________________________

9. If Plaintiff and Defendant are parents of any minor child/ren together, is there an existing court order regarding their custody?

If you answered “Yes”, describe the terms of the order (e.g., primary, shared, legal and/or physical custody):

If you answered “Yes”, in what county and state was the order issued? ________

If you are now seeking an order of child custody as part of this petition, list the following information:

(a) Where has each child resided during the past five years?

Child's name Person(s) child lived with Address, unless confidential
When

______________ ___________________________ ________________ ________________

(b) List any other persons who are known to have or claim a right to custody of each child listed above.

Name Address Basis of Claim

_____________________ _______________________ ______________________________

10. The following other minor child/ren presently live with Plaintiff:

Name(s) Age(s) Plaintiff's relationship to child/ren

______________ ___________ ___________________________________________________

11. The facts of the most recent incident of abuse are as follows:

Approximate Date: ____________________________________________________________

Approximate Time: ____________________________________________________________

Place: _______________________________________________________________________

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):

12. If Defendant has committed prior acts of abuse against Plaintiff or the minor child/ren, describe these prior incidents, including any threats, injuries, or incidents of stalking, and indicate approximately when such acts of abuse occurred (attach additional sheets of paper if necessary):

13. (a) Has Defendant used or threatened to use any firearms or other weapons against Plaintiff or the minor child/ren? If so, please describe the use or threatened use below and list on Attachment A to Petition, which is incorporated by reference into this petition, any firearms, other weapons or ammunition Defendant used or threatened to use against Plaintiff and/or the minor child/ren:

(b) Other than the firearms, other weapons or ammunition Defendant used or threatened to use against Petitioner or the minor child/ren, does Defendant, to the best of your knowledge or belief, own or possess any additional firearm, other weapon, ammunition or any firearm license?

(c) If the answer to (b) above is “yes,” list any additional firearm, other weapon or ammunition owned by or in the possession of Defendant on Attachment A to Petition, which is incorporated by reference into this petition.

(d) Plaintiff (check one) [ ]DOES [ ]DOES NOT request that the court order Defendant to relinquish firearms, other weapons or ammunition listed on Attachment A to Petition. If Plaintiff does seek relinquishment, identify on Attachment A to Petition the firearms, other weapons and ammunition Plaintiff requests the court to order Defendant to relinquish.

14. Identify the sheriff, police department or law enforcement agency in the area in which Plaintiff lives that should be provided with a copy of the protection order:

15. There is an immediate and present danger of further abuse from Defendant.

CHECK THE FOLLOWING BOXES ONLY IF THEY APPLY TO YOUR CASE AND PROVIDE THE REQUESTED INFORMATION

[ ] Plaintiff is asking the court to evict and exclude Defendant from the following residence:

[ ] owned by (list owners, if known): __________________________________________

[ ] rented by (list all names, if known): ______________________________________

[ ] Defendant owes a duty of support to Plaintiff and/or the minor child/ren.

[ ] Plaintiff has suffered out-of-pocket financial losses as a result of the abuse described above. Those losses are:

FOR THE REASONS SET FORTH ABOVE, I REQUEST THAT THE COURT ENTER A TEMPORARY ORDER, AND AFTER HEARING, A FINAL ORDER THAT WOULD DO THEFOLLOWING (CHECK ALL FORMS OF RELIEF REQUESTED):

[ ] A. Restrain Defendant from abusing, threatening, harassing, or stalking Plaintiff and/or the minor child/ren in any place where Plaintiff and/or the child/ren may be found.

[ ] B. Evict/exclude Defendant from Plaintiff's residence and prohibit Defendant from attempting to enter any temporary or permanent residence of Plaintiff.

[ ] C. Require Defendant to provide Plaintiff and/or the minor child/ren with other suitable housing.

[ ] D. Award Plaintiff temporary custody of the minor child/ren and place the following restrictions on contact between Defendant and the child/ren:

[ ] E. Prohibit Defendant from having any contact with Plaintiff and/or the minor child/ren, either in person, by telephone, or in writing, personally or through third persons, including but not limited to any contact at Plaintiff's school, business, or place of employment, except as the court may find necessary with respect to partial custody and/or visitation with the minor child/ren.

[ ] F. Prohibit Defendant from having any contact with Plaintiff's relatives and Plaintiff's children listed in this petition, except as the court may find necessary with respect to partial custody and/or visitation with the minor child/ren. The following persons are Plaintiff's relatives or family and household members that Plaintiff believes require protection from stalking and harassment by Defendant.

Name Address (optional) Relationship to Plaintiff

_____________________________________________________________________________

[ ] G. Order Defendant to temporarily relinquish some or all of the firearms, other weapons and/or ammunition listed on Attachment A to Petition and any firearm license to the sheriff of this county and/or prohibit Defendant from transferring, acquiring or possessing some or all firearms for the duration of the order.

[ ] H. Order Defendant to pay temporary support for Plaintiff and/or the minor child/ren, including medical support and

[ ] payment of the rent or mortgage on the residence.

[ ] I. Direct Defendant to pay Plaintiff for the reasonable financial losses suffered as the result of the abuse, to be determined at the hearing.

[ ] J. Order Defendant to pay the costs of this action, including filing and service fees.

[ ] K. Order Defendant to pay Plaintiff's reasonable attorney's fees.

[ ] L. Order the following additional relief, not listed above: ________________

[ ] M. Grant such other relief as Plaintiff requests and/or the court deems appropriate.

[ ] N. 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 hearing. Plaintiff will inform the designated authority of any addresses, other than Defendant's residence, where Defendant can be served.

VERIFICATION

I verify that I am the petitioner as designated in the present action and that the facts and statements contained in the above petition are true and correct to the best of my knowledge. I understand that any false statements are made subject to the penalties of 18 Pa.C.S.A. § 4904, relating to unsworn falsification to authorities.

________________________________________________________________________________

Signature

________________________________________________________________________________

Date

(Caption)

ATTACHMENT A TO PETITION

FIREARMS, OTHER WEAPONS, AND

AMMUNITION INVENTORY

I, __________, Plaintiff in this Protection From Abuse Action, hereby

(a) state that Defendant used or threatened to use the following firearms, other weapons, and ammunition, and firearm licenses to the sheriff against Plaintiff and/or the minor child/ren (include addresses or locations, if known, such as “front seat of blue truck,” “gun cabinet,” “bedroom closet,” etc.):

Firearm/Other Weapon/Ammunition

Location

4.
5.

(b) state that Defendant, to the best of my knowledge or belief, owns or possesses the following firearms, other weapons or ammunition not set forth in (a) above (include addresses or locations, if known):

Firearm/Other Weapon/Ammunition

Location

(c) request that the court order Defendant to relinquish the following firearms, other weapons and ammunition (include addresses or locations, if known):

Firearm/Other Weapon/Ammunition

Location
1.

[ ] All firearms, other weapons and ammunition owned or possessed by Defendant.

If more space is needed, more sheets may be attached to this document.

Name ________________________________________________________________________________

Date ________________________________________________________________________________

Notice: This attachment will be withheld from public inspection in accordance with 23 Pa.C.S.A. § 6108(a)(7)(v).

(c) The Temporary Order of Court, or any continued, amended or modified Temporary Order of Court, entered pursuant to the Act shall be substantially in the following form, but the first page must be exactly as set forth in this rule:

TEMPORARY PROTECTION FROM ABUSE ORDER IN THE COURT OF COMMON PLEAS OF __________

COUNTY, PENNSYLVANIA

[ ] Amended Order [ ] Continued Order NO.

PLAINTIFF

First Middle Last Plaintiff's DOB

Name(s) of all protected persons, including minor child/ren and DOB:

_________________________________________________________________

DEFENDANT

First Middle Last Suffix

Defendant's Address: DEFENDANT IDENTIFIERS

_____________________________ DOB HEIGHT

_____________________________ SEX WEIGHT

_____________________________ RACE EYES

_____________________________ HAIR

SSN

CAUTION: DRIVER'S

[ ] Weapon Involved LICENSE #

[ ] Weapon Present on the Property EXP DATE STATE

[ ] Weapon Ordered Relinquished

The Court Hereby Finds: That it has jurisdiction over the parties and subject matter, and the Defendant will be provided with reasonable notice and opportunity to be heard.

The Court Hereby Orders:

[ ] Defendant shall not abuse, harass, stalk or threaten any of the above persons in any place where they might be found.

[ ] Except for such contact with the minor child/ren as may be permitted under paragraph 5 of this order, Defendant shall not contact Plaintiff, or any other person protected under this order, by telephone or by any other means, including through third persons.

[ ] Additional findings of this order are set forth below.

Order Effective Date__________Order Expiration Date_____________________________________

NOTICE TO THE DEFENDANT

Defendant is hereby notified that violation of this order may result in arrest for indirect criminal contempt, which is punishable by a fine of up to $1,000 and/or up to six months in jail. 23 Pa.C.S.A. § 6114. Consent of Plaintiff to Defendant's return to the residence shall not invalidate this order, which can only be changed or modified through the filing of appropriate court papers for that purpose. 23 Pa.C.S.A. § 6108 (g). If Defendant is required to relinquish any firearms, other weapons or ammunition or any firearm license, those items must be relinquished to the sheriff within 24 hours of the service of this order. As an alternative, Defendant may relinquish any firearm, other weapon or ammunition listed herein to a third party provided Defendant and the third party first comply with all requirements to obtain a safekeeping permit. If, due to their current location, firearms, other weapons or ammunition cannot reasonably e retrieved within the time for relinquishment, Defendant shall provide an affidavit to the sheriff listing the firearms, other weapons or ammunition and their current location no later than 24 hours after the service of this order.
Defendant is further notified that violation of this order may subject him/her to state charges and penalties under the Pennsylvania Crimes Code and to federal charges and penalties under the Violence Against Women Act, 18 U.S.C. §§ 2261-2262.

AND NOW, this ___ day of __________, 20___, upon consideration of the attached Petition for Protection From Abuse, the court hereby enters the following Temporary Order:

[ ] Plaintiff's request for a Temporary Protection Order is denied.

[ ] Plaintiff's request for a Temporary Protection Order is granted.

[ ] 1. Defendant shall not abuse, harass, stalk or threaten any of the above persons in any place where they might be found.

[ ] 2. Defendant is evicted and excluded from the residence at [NONCONFIDENTIAL ADDRESS FROM WHICH

DEFENDANT IS EXCLUDED] or any other permanent or temporary residence

where Plaintiff or any other person protected under this order may live. Plaintiff is granted exclusive possession of the residence. Defendant shall have no right or privilege to enter or be present on the premises of Plaintiff or any other person protected under this order.

[ ] 3. Except for such contact with the minor child/ren as may be permitted under Paragraph 5 of this order, Defendant is prohibited from having ANY CONTACT with Plaintiff, or any other person protected under this order, either directly or indirectly, at any location, including but not limited to any contact at Plaintiff's school, business, or place of employment. Defendant is specifically ordered to stay away from the following locations for the duration of this order:

[ ] 4. Except for such contact with the minor child/ren as may be permitted under Paragraph 5 of this order, Defendant shall not contact Plaintiff, or any other person protected under this order, by telephone or by any other means, including through third persons.

[ ] 5. CUSTODY.

[ ] There is a current custody order as to the child/ren of the parties:

(county court)

(docket number)

[ ] THIS ORDER SHALL NOT SUPERSEDE THE CURRENT CUSTODY ORDER.

[ ] THIS ORDER SUPERSEDES ANY PRIOR ORDER RELATING TO CHILD CUSTODY.

[ ] Until the final hearing, all contact between Defendant and the child/ren shall be limited to the following:

[ ] Pending the outcome of the final hearing in this matter, Plaintiff is awarded temporary custody of the following minor child/ren:

The local law enforcement agency in the jurisdiction where the child/ren are located shall ensure that the child/ren are placed in the care and control of the Plaintiff in accordance with the terms of this order.

[ ] 6. FIREARMS, OTHER WEAPONS AND AMMUNITION RESTRICTIONS

Check all that apply:

[ ] Defendant is prohibited from possessing, transferring or acquiring any firearms for the duration of this order.

[ ] Defendant shall relinquish to the sheriff the following firearms licenses owned or possessed by Defendant:

[ ] Defendant is directed to relinquish to the sheriff any firearm, other weapon or ammunition listed in Attachment A to Temporary Order, which is incorporated herein by reference.

Defendant may relinquish any firearms, other weapons or ammunition to the sheriff. As an alternative, Defendant may relinquish firearms, other weapons and ammunition to a third party provided Defendant and the third party first comply with all the requirements to obtain a safekeeping permit. Defendant must relinquish any firearm, other weapon, mmunition or firearm license ordered to be relinquished no later than 24 hours after service of this order. If, due to their current location, firearms, other weapons or ammunition cannot reasonably be retrieved within the time for relinquishment, Defendant shall provide to the sheriff an affidavit listing the firearms, other weapons or ammunition and their current location no later than 24 hours after service of this order. Failure to timely relinquish any firearm, other weapon, ammunition or any firearm license shall result in a violation of this order and may result in criminal conviction under the Uniform Firearms Act, 18 Pa.C.S.A. § 6105.

[ ] 7. The following additional relief is granted:

[ ] Defendant is prohibited from stalking, as defined in 18 Pa.C.S.A. § 2709.1, or harassing, as defined in 18 Pa.C.S.A. § 2709, the following family and household members of Plaintiff:

Name Address (optional) Relationship to Plaintiff

_____________________________________________________________________________

[ ] Other relief: ______________________________________________________________

[ ] 8. A certified copy of this order shall be provided to the sheriff or police department where Plaintiff resides and any other agency specified hereafter: [insert name of agency]

[ ] 9. THIS ORDER SUPERSEDES ANY PRIOR PROTECTION FROM ABUSE ORDER OBTAINED BY THE SAME

PLAINTIFF AGAINST THE SAME DEFENDANT.

[ ] 10. THIS ORDER APPLIES IMMEDIATELY TO DEFENDANT AND SHALL REMAIN IN EFFECT UNTIL [insert expiration date] OR UNTIL OTHERWISE MODIFIED OR TERMINATED

BY THIS COURT AFTER NOTICE AND HEARING.

NOTICE TO THE DEFENDANT

Defendant is hereby notified that violation of this order may result in arrest for indirect criminal contempt, which is punishable by a fine of up to $1,000 and/or up to six months in jail. 23 Pa.C.S.A. § 6114. Consent of Plaintiff to Defendant's return to the residence shall not invalidate this order, which can only be changed or modified through the filing of appropriate court papers for that purpose. 23 Pa.C.S.A. § 6108.(g). If Defendant is required to relinquish any firearms, other weapons or ammunition or any firearm license, those items must be relinquished to the sheriff within 24 hours of the service of this order. As an alternative, Defendant may relinquish any firearm, other weapon or ammunition listed herein to a third party provided Defendant and the third party first comply with all requirements to obtain a safekeeping permit. If, due to their current location, firearms, other weapons or ammunition cannot reasonably be retrieved within the time for relinquishment, Defendant shall provide an affidavit to the sheriff listing the firearms, other weapons or ammunition and their current location no later than 24 hours after service of this order. Defendant is further notified that violation of this order may subject him/her to state charges and penalties under the Pennsylvania Crimes Code and to federal charges and penalties under the Violence Against Women Act, 18 U.S.C. §§ 2261--2262.

NOTICE TO SHERIFF, POLICE AND LAW ENFORCEMENT OFFICIALS

This order shall be enforced by the police department or sheriff who has jurisdiction over Plaintiff's residence OR any location where a violation of this order occurs OR where Defendant may be located. If Defendant violates Paragraphs 1 through 6 of this order, Defendant shall be arrested on the charge of indirect criminal contempt. An arrest for violation of this order may be made without warrant, based solely on probable cause, whether or not the violation is committed in the presence of a police officer or sheriff.

Subsequent to an arrest, the law enforcement officer or sheriff shall seize all firearms, other weapons and ammunition in Defendant's possession which were used or threatened to be used during the violation of the protection order or during prior incidents of abuse and any other firearms in Defendant's possession. Any firearm, other weapon, ammunition or any firearm license must be delivered to the sheriff's office of the county which issued this order, which office shall maintain possession of the firearms, other weapons and ammunition until further order of this court, unless the weapon/s are evidence of a crime, in wh ch case, they shall remain with the law enforcement agency whose officer or sheriff made the arrest.

BY THE COURT:

________________________________________________________________________________

Judge

________________________________________________________________________________

Date

(Caption)

ATTACHMENT A TO TEMPORARY ORDER

FIREARMS, OTHER WEAPONS AND

AMMUNITION INVENTORY

It is hereby ordered that Defendant relinquish the following firearms, other weapons and ammunition to the sheriff:
Firearm/Other Weapon/Ammunition Location

10.

[ ] All firearms, other weapons and ammunition owned or possessed by the defendant.

BY THE COURT:

________________________________________________________________________________

Judge

________________________________________________________________________________

Date

Notice: This attachment will be withheld from public inspection in accordance with 23 Pa.C.S.A. § 6108(a)(7)(v).

(d) The form of the Affidavit of Service in a Protection From Abuse matter shall be substantially in the following form:

(Caption)

AFFIDAVIT OF SERVICE

I, __________, the undersigned, hereby state that I served a copy of the Notice of Hearing and Order, Petition and Temporary Order in the above-captioned action upon Defendant by handing the papers to __________ at the following address: ____________________ on the ___ day of __________, 20___, at approximately ___ o'clock ___.m.

I verify that the statements made in this Affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.A. § 4904, relating to unsworn falsification to authorities.

(Signature) __________________________________________________________________

(Title) ______________________________________________________________________

(Address) ____________________________________________________________________

(Date) _______________________________________________________________________

THIS FORM MUST BE COMPLETED AND SIGNED BY THE PERSON WHO SERVES THE DEFENDANT WITH THE

NOTICE OF HEARING AND ORDER, PETITION AND

TEMPORARY ORDER. IT MUST BE FILED WITH THE PROTHONOTARY OR BROUGHT TO THE COURT ON THE

HEARING DATE.

(e) The Final Order of Court, or any amended, modified or extended Final Order of Court, entered pursuant to the Act shall be substantially in the following form, but the first page must be exactly as set forth in this rule:

FINAL PROTECTION FROM ABUSE ORDER IN THE COURT OF COMMON PLEAS OF __________

COUNTY, PENNSYLVANIA

[ ] Extended Order [ ] Amended Order NO.

PLAINTIFF

First Middle Last Plaintiff's DOB

Name(s) of all protected persons, including minor child/ren and DOB:

_________________________________________________________________

DEFENDANT

First Middle Last Suffix

Defendant's Address: DEFENDANT IDENTIFIERS

_____________________________ DOB HEIGHT

    _____________________________                         SEX                             WEIGHT
    _____________________________                         RACE                             EYES
    _____________________________                             HAIR

SSN

CAUTION: DRIVER'S

[ ] Weapon Involved LICENSE #

[ ] Weapon Present on the Property EXP DATE STATE

[ ] Weapon Ordered Relinquished

The Court Hereby Finds: That it has jurisdiction over the parties and subject matter, and the Defendant has been provided with reasonable notice and opportunity to be heard.

The Court Hereby Orders:

[ ] Defendant shall not abuse, harass, stalk or threaten any of the above persons in any place where they might be found.

[ ] Except as provided in paragraph 5 of this order, Defendant shall not contact Plaintiff, or any other person protected under this order, by telephone or by any other means, including through third persons.

[ ] Additional findings of this order are set forth below.

Order Effective Date __________ Order Expiration Date __________________________________

NOTICE TO THE DEFENDANT

Violation of this order may result in your arrest on the charge of indirect criminal contempt which is punishable by a fine of up to $1,000 and/or a jail sentence of up to six months. 23 Pa.C.S.A. § 6114. Violation may also subject you to prosecution and criminal penalties under the Pennsylvania Crimes Code. A violation of this order may result in the revocation of the safekeeping permit, which will require the immediate relinquishment of your firearms, other weapons and ammunition to the sheriff. Plaintiff's consent to contact by Defendant shall not invalidate this order which can only be modified by further order of court. 23 Pa.C.S.A. § 6108(g).

This order is enforceable in all fifty (50) States, the District of Columbia, Tribal Lands, U.S. Territories and the Commonwealth of Puerto Rico under the Violence Against Women Act, 18 U.S.C. § 2265. If you travel outside of the State and intentionally violate this order, you may be subject to federal criminal proceedings under that Act. 18 U.S.C §§ 2261-2262. If you possess a firearm or any ammunition while this order is in effect, you may be charged with a federal offense even if this Pennsylvania order does not expressly prohibit you from possessing firearms or ammunition. 18 U.S.C § 922(g)(8).

CHECK ALL THAT APPLY:

Plaintiff or Protected Person(s) is/are:

[ ] spouse or former spouse of Defendant

[ ] parent of a child with Defendant

[ ] current or former sexual or intimate partner with Defendant

[ ] child of Plaintiff

[ ] child of Defendant

[ ] family member related by blood (consanguinity) to Defendant

[ ] family member related by marriage or affinity to Defendant

[ ] sibling (person who shares parenthood) of Defendant

Defendant was served in accordance with Pa.R.C.P. 1930.4 and provided notice of the time, date and location of the hearing scheduled in this matter.

AND NOW, this ___ day of __________, 20___, the court having jurisdiction over the parties and the subject-matter, it is ORDERED, ADJUDGED AND DECREED as follows:

This order is entered (check one) [ ]by agreement [ ]by agreement without an admission, [ ]after a hearing and decision by the court [ ]after a hearing at which Defendant was not present, despite proper service being made [ ]by default. Without regard as to how the order was entered, this is a final order of court subject to full enforcement pursuant to the Protection From Abuse Act.

Note: Space is provided to allow for 1) the court's general findings of abuse; 2) inclusion of the terms under which the order was entered (e.g., that the order was entered with the consent of the parties, or that the defendant, though properly served, failed to appear for the hearing, or the reasons why the plaintiff's request for a final PFA order was denied); and/or 3) information that may be helpful to law enforcement (e.g., whether a firearm or other weapon was involved in the incident of abuse and/or whether the defendant is believed to be armed and dangerous.

[ ] Plaintiff's request for a final protection order is denied.

[ ] Plaintiff's request for a final protection order is granted.

[ ] 1. Defendant shall not abuse, stalk, harass, threaten or attempt to use physical force that would reasonably be expected to cause bodily injury to Plaintiff or any other protected person in any place where they might be found.

[ ] 2. Defendant is completely evicted and excluded from the residence at (NONCONFIDENTIAL ADDRESS FROM WHICH DEFENDANT IS EXCLUDED) or any other residence where Plaintiff or any other person protected under this order may live. Exclusive possession of the residence is granted to Plaintiff. Defendant shall have no right or privilege to enter or be present on the premises of Plaintiff or any other person protected under this order.

[ ] On [insert date and time], Defendant may enter the residence to retrieve his/her clothing and other personal effects, provided that Defendant is in the company of a law enforcement officer or sheriff when such retrieval is made and [insert any other conditions]

[ ] 3. Except as provided in paragraph 5 of this order, Defendant is prohibited from having ANY CONTACT with Plaintiff, either directly or indirectly, or any other person protected under this order, at any location, including but not limited to any contact at Plaintiff's school, business, or place of employment. Defendant is specifically ordered to stay away from the following locations for the duration of this order:

[ ] 4. Except as provided in paragraph 5 of this order, Defendant shall not contact Plaintiff, either directly or indirectly, or any other person protected under this order, by telephone or by any other means, including through third persons.

[ ] 5. Temporary custody of the minor children, [NAMES OF THE CHILDREN SUBJECT TO THE PROVISION OF THIS PARAGRAPH] shall be as follows:

Check all that apply:

[ ] STATE TO WHOM PRIMARY PHYSICAL CUSTODY IS AWARDED; STATE TERMS OF PARTIAL CUSTODY OR

VISITATION, IF ANY.

[ ] There is a current custody order as to the children of the parties:

(county court)

(docket number)

[ ] A custody petition is pending.

[ ] A hearing is scheduled for ____________________ (date, time and location)

[ ] THIS ORDER SHALL NOT SUPERSEDE THE CURRENT CUSTODY ORDER.

[ ] THIS ORDER SUPERSEDES ANY PRIOR ORDER RELATING TO CHILD CUSTODY.

[ ] 6. FIREARMS, OTHER WEAPONS AND AMMUNITION RESTRICTIONS

Check all that apply:

[ ] Defendant is prohibited from possessing, transferring or acquiring any firearms for the duration of this order.

[ ] Defendant shall relinquish to the sheriff the following firearms licenses owned or possessed by Defendant:

[ ] Defendant is directed to relinquish to the sheriff any firearm, other weapon or ammunition listed in Attachment A to Final Order, which is incorporated herein by reference.

Defendant may relinquish any firearms, other weapons or ammunition to the sheriff. As an alternative, Defendant may either relinquish firearms, other weapons and ammunition to a third party provided Defendant and third party first comply with all the requirements to obtain a safekeeping permit, or relinquish firearms, other weapons and ammunition to a licensed firearms dealer for consignment sale, lawful transfer or safekeeping pursuant to 23 Pa.C.S.A. § 6108.2(e). Defendant must relinquish any firearm, other weapon, ammunition or firearms license ordered to be relinquished no later than 24 hours after service of this order. Failure to timely relinquish any firearm, other weapon, ammunition or any firearm license ordered to be relinquished shall result in a violation of this order and may result in criminal conviction under the Uniform Firearms Act, 18 Pa.C.S.A. § 6105.

[ ] 7. Any firearm delivered to the sheriff or transferred to a licensed firearm dealer, or a qualified third party who satisfies the procedural and substantive requirements to obtain a safekeeping permit issued under 23 Pa.C.S.A. § 6108.3 pursuant to this order or the temporary order shall not be returned to Defendant until further order of court or as otherwise provided by law.

[ ] 8. The following additional relief is granted as authorized by § 6108 of the Act:

[ ] Defendant is prohibited from stalking, as defined in 18 Pa.C.S. § 2709.1, or harassing, as defined in 18 Pa.C.S. § 2709, the following family and household members of Plaintiff:

Name Address (optional) Relationship to Plaintiff

_____________________________________________________________________________
_____________________________________________________________________________

_____________________________________________________________________________

[ ] Other relief: ______________________________________________________________

[ ] 9. Defendant is directed to pay temporary support for: [INSERT THE NAMES OF THE PERSONS FOR WHOM SUPPORT IS TO BE PAID] as follows: [INSERT AMOUNT, FREQUENCY AND OTHER TERMS AND CONDITIONS OF THE SUPPORT ORDER]. This order for support shall remain in effect until a final support order is entered by this court. However, this order shalllapse automatically if Plaintiff does not file a complaint for support with the Domestic Relations Section of the court within two weeks of the date of this order. The amount of this temporary order does not necessarily reflect Defendant's correct support obligation, which shall be determined in accordance with the guidelines at the support hearing. Any adjustments in the final amount of support shall be credited, retroactive to this date, to the appropriate party.

10. [ ] (a) The costs of this action are imposed on Defendant.

[ ] (b) Because this order followed a contested proceeding, or a hearing at which Defendant was not present, despite being served with a copy of the petition, temporary order and notice of the date, time and place of the hearing, Defendant is ordered to pay an additional $100 surcharge to the court, which shall be distributed in the manner set forth in 23 Pa.C.S.A. § 6106(d).

[ ] (c) Upon a showing of good cause or a finding that Defendant is unable to pay, the costs of this action are waived.

[ ] 11. Defendant shall pay $ ___ to Plaintiff by (insert date) as compensation for Plaintiff's out-of-pocket losses, which are as follows:

An installment schedule is ordered as follows:

[ ] Plaintiff is granted leave to present a petition, with appropriate notice to Defendant, to [INSERT THE NAME OF THE JUDGE OR COURT TO WHICH THE PETITION SHOULD BE PRESENTED] requesting recovery of out-of-pocket losses. The petition shall include an exhibit itemizing all claimed ut-of-pocket losses, copies of all bills and estimates of repair, and an order scheduling a hearing. No fee shall be required by the prothonotary's office for the filing of this petition.

[ ] 12. THIS ORDER SUPERCEDES ANY PRIOR PROTECTION FROM ABUSE ORDER OBTAINED BY THE SAME PLAINTIFF AGAINST THE SAME DEFENDANT.

13. All provisions of this order shall expire:

Check one

[ ] in [INSERT DAYS, MONTHS OR YEARS] on [INSERT EXPIRATION DATE]

[ ] in three years, on [INSERT EXPIRATION DATE]

NOTICE TO THE DEFENDAN

VIOLATION OF THIS ORDER MAY RESULT IN YOUR ARREST ON THE CHARGE OF INDIRECT CRIMINAL CONTEMPT WHICH IS PUNISHABLE BY A FINE OF UP TO $1,000 AND/OR A JAIL SENTENCE OF UP TO SIX MONTHS. 23 PA.C.S.A. § 6114. VIOLATION MAY ALSO SUBJECT YOU TO PROSECUTION AND CRIMINAL PENALTIES UNDER THE PENNSYLVANIA CRIMES CODE. A VIOLATION OF THIS ORDER MAY RESULT IN THE REVOCATION OF THE SAFEKEEPING PERMIT, WHICH WILL REQUIRE THE IMMEDIATE RELINQUISHMENT OF YOUR FIREARMS, OTHER WEAPONS AND AMMUNITION TO THE SHERIFF. PLAINTIFF'S CONSENT TO CONTACT BY DEFENDANT SHALL NOT INVALIDATE THIS ORDER WHICH CAN ONLY BE MODIFIED BY FURTHER ORDER OF COURT. 23 Pa.C.S.A. § 6108(g).

THIS ORDER IS ENFORCEABLE IN ALL FIFTY (50) STATES, THE DISTRICT OF COLUMBIA, TRIBAL LANDS, U.S. TERRITORIES AND THE COMMONWEALTH OF PUERTO RICO UNDER THE VIOLENCE AGAINST WOMEN ACT, 18 U.S.C. § 2265. IF YOU TRAVEL OUTSIDE OF THE STATE AND INTENTIONALLY VIOLATE THIS ORDER, YOU MAY BE SUBJECT TO FEDERAL CRIMINAL PROCEEDINGS UNDER THAT ACT. 18 U.S.C. §§ 2261--2262. IF YOU POSSESS A FIREARM OR ANY AMMUNITION WHILE THIS ORDER IS IN EFFECT, YOU MAY BE CHARGED WITH A FEDERAL OFFENSE EVEN IF THIS PENNSYLVANIA ORDER DOES NOT EXPRESSLY PROHIBIT YOU FROM POSSESSING FIREARMS OR AMMUNITION. 18 U.S.C. § 922(g)(8).

NOTICE TO SHERIFF, POLICE AND LAW ENFORCEMENT OFFICIALS

The police and sheriff who have jurisdictioover Plaintiff's residence OR any location where a violation of this order occurs OR where Defendant may be located, shall enforce this order. The court shall have jurisdiction over any indirect criminal contempt proceeding, either in the county where the violation occurred or where this protective order was entered. An arrest for violation of paragraphs 1 through 7 of this order may be without warrant, based solely on probable cause, whether or not the violation is committed in the presence of the police or any sheriff. 23 Pa.C.S.A. § 6113.

Subsequent to an arrest, and without the necessity of a warrant, the police officer or sheriff shall seize all firearms, other weapons and ammunition in Defendant's possession that were used or threatened to be used during the violation of the protection order or during prior incidents of abuse and any other firearms in Defendant's possession. The [insert the appropriate name or title] shall maintain possession of the firearms, other weapons or ammunition until further order of this court.

When Defendant is placed under arrest for violation of the order, Defendant shall be taken to the appropriate authority or authorities before whom Defendant is to be arraigned. A “Complaint for Indirect Criminal Contempt” shall then be completed and signed by the police officer, sheriff OR Plaintiff. Plaintiff's presence and signature are not required to file the complaint.

If sufficient grounds for violation of this order are alleged, Defendant shall be arraigned, bond set, if appropriate and both parties given notice of the date of hearing.

BY THE COURT:

Judge ________________________________________________________________________________

Date ________________________________________________________________________________

If entered pursuant to the consent of plaintiff and defendant:

________________________________________________________________________________

(Plaintiff's signature)

________________________________________________________________________________
(Defendant's signature)

(Caption)
ATTACHMENT A TO FINAL ORDER

FIREARMS, OTHER WEAPONS AND

AMMUNITION INVENTORY

It is hereby ordered that Defendant relinquish the following firearms, other weapons and ammunition to the sheriff:

Firearm/Other Weapon/Ammunition Location

4.
5.

6.
7.

10.

[ ] All firearms, other weapons and ammunition owned or possessed by Defendant.

BY THE COURT:

________________________________________________________________________________

    Judge
    ________________________________________________________________________________
    Date

Notice: This attachment will be withheld from public inspection in accordance with 23 Pa.C.S.A. § 6108(a)(7)(v).