Instructions for Completing the Custody Forms if you DO have a current
Custody Order In Mercer County
THE INFORMATION REQUESTED IN THE FOLLOWING FORMS SHOULD BE
TYPED OR NEATLY PRINTED IN THE BLANKS PROVIDED
A.
Body of the Petition for Modification:
1) Complete the caption of the Petition by filling in the names of the parties exactly as they are
found in your previous court order. Also use the same civil number found on your previous
court order.
2) At the first blank line, after the words “AND NOW comes the _____”, write in either
“Plaintiff” or “Defendant” depending on how you are listed in the caption. If you are listed as the
Plaintiff in the caption, then you should fill in “Plaintiff” on the first blank line. If you are listed
as the Defendant in the caption, then you should fill in “Defendant” on the first blank line.
3) At number "1", fill in the date of your previous court order after the words "that on".
You should also circle the type of custody that the Court entered. This can be found in your
previous court order.
4) At number "2", fill in the information about the plaintiff. First fill in the Plaintiff’s name on
the first blank line. Next, after the word “natural”, fill in the Plaintiff’s relationship with the
child/children. Next, fill in the Plaintiff’s address.
5) At number “3”, fill in the information about the Defendant. Fill in the Defendant’s name on
the first blank line. Next, after the word “natural”, fill in the Defendant’s relationship with the
child/children. Next, fill in the Defendant’s address.
6) At number “4”, fill in the information about the children that the parties are parents to.
7) Number “5” asks about the current custody order in place. In the first blank, fill in the date
of the Court’s Order. In the second blank, fill in names of the parties who were granted “legal
custody.” In the third line, fill in the name of the parties who have “primary physical custody.”
In the fourth line, fill in the name of the party who has partial custody/visitation with the child.
This information will all be found in your current custody order.
8) Number “6”, asks who is requesting the modification and why. On the first blank line, fill in
whether you are the Plaintiff or Defendant. On the remaining lines, explain why you believe the
previous court order should be modified. For example, have you or the other parent moved, has
the other parent's situation gotten worse or has yours gotten better, or does the child now express
an interest that he/she wants to live with you primarily? Remember that space is limited, so here
you will want to hit only the highlights.
9) Number “7” states that you have filled out and included with the Petition to Modify, a
“Criminal Record / Abuse History” form.
10) Finally, sign the Petition on the line provided.
11) Attach a copy of your previous court order to the Petition before you file it with the court!
B.
Criminal Record / Abuse History Verification
1) You must complete and file this form with the Petition. There are two copies of this form in
this packet. You must complete one and file it with your modification petition. You must
include the other blank form with the petition when you serve the opposing party. This form
may be used by the Court during your custody proceedings.
2) Complete the caption of this form by filling in the names of the parties exactly as they are
found in your previous order of court. Also use the same civil number found on your
previous court order.
3) Fill in the first blank line with your name.
4) You must check the box next to a crime that either you or a household member has been
convicted of, pled guilty to, or pled no contest to. You must also answer the questions that
follow, if applicable. You must be truthful on this form or you could be fined at least
$1,000. If you are not sure of a crime that you or a household member should list, you can
visit the website listed which provides access to search, view and print the docket sheets for
Pennsylvania’s courts. You should check both the Magisterial Court Docket Sheets and the
Court of Common Pleas Docket Sheet:
http://ujsportal.pacourts.us/DocketSheets/MDJ.aspx
5) Complete the remaining form if applicable.
C.
Verification
1) Complete the caption of the Verification in exactly the same way that you completed the
caption of the Petition.
2) Fill in your name on the first blank.
3) Sign and date the bottom in the spaces provided.
4) By signing this form, you are stating that the information you provided in this petition are
true to the best of your knowledge.
D.
Order and Notice
1) Complete the caption of the Order and Notice in exactly the same way that you
completed the caption of the Petition.
2) After the word “TO:” fill in the name of the party that you are sending this order to.
3) In the first line of the Order and Notice, after the word "you" insert the name of the
other party. You should then circle the type of custody that was granted in your current
order. Then after the word "child(ren)" insert the name(s) of the child or children who
are the subject of your case.
4) On the last page of the scheduling order, there is a paragraph that tells the defendant that
he or she must file with the Court a “Criminal History/ Abuse History” form. This form
will be included in the complaint.
5) Also on the last page of the scheduling order there is a paragraph that lets the opposing
party know that no party can change the child’s residence which would impair the other
party’s ability to exercise custodial rights without following the required relocation
procedures.
6) After the words "BY THE COURT", leave the lines for the date and the
Judge's signature blank. The Judge will sign and date the order.
E.
Order Appointing Master
1) Complete the caption of the Order Appointing Master in exactly the same way that you
completed the caption of the Petition.
2) You should not fill in anything else on this page. The court will fill this out and send it
back to you.
3) On the next page, you should not fill in anything. The judge will sign this.
F.
Certificate of Service
1) Complete the caption of the Certificate of Service in exactly the same way that you
completed the caption of the Petition.
2) Fill in your name on the first blank line.
3) Fill in the name(s) and address(es) for all the opposing parties in your case. These are the
people you will need to send a copy of these documents to.
4) Sign your name, fill in your address, and the date.
G.
Criminal Record / Abuse History Verification
1)
A second copy of the Criminal History / Abuse History Verification is included in
this packet. It must be sent to the defendant when you send the Modification. The
defendant must fill this form out and file it with the Court.
IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
__________________________________,
Plaintiff
vs.
__________________________________,
Defendant
:
:
:
:
:
:
:
:
:
No.
PETITION FOR MODIFICATION OF CUSTODY ORDER
AND NOW comes the
following:
1.
, and respectfully represents the
That on _______________, 20___ an Order of Court was entered for (Shared
Legal Custody) (Sole Legal Custody) (Partial Physical Custody) (Primary
Physical Custody) (Shared Physical Custody) (Sole Physical Custody)
(Supervised Physical Custody). A true and correct copy of which is attached.
2.
The plaintiff is
, natural
, who
resides at
3.
.
The Defendant is
, natural
,
who resides at
4.
.
Parties are the parents of the following child(ren):
Name
Present Residence
Date of Birth
____________________
_____________________
_______________
____________________
_____________________
_______________
5.
The Court’s Order of
, gave legal custody to
, primary physical custody of the
minor child(ren) to
subject to
visitation/partial custody by
6.
The
.
requests a modification of this Court’s prior
order because: _____________________________________________________
__________________________________________________________________
_________________________________________________________________.
7.
I have attached the Criminal Record/Abuse History Verification form required
pursuant to Pa.R.C.P. No. 1915.3-2.
WHEREFORE, Petitioner requests that the Court modify the existing Order because it
will be in the best interest of the child(ren).
Respectfully submitted:
____________________________________
Petitioner, Pro Se
IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
,
Plaintiff
vs.
,
Defendant
:
:
:
:
:
:
:
:
No.
______________________________________________________________________________
CRIMINAL RECORD / ABUSE HISTORY VERIFICATION
I, ________________________________, hereby swear or affirm, subject to penalties of
law including 18 Pa. C.S. §4904 relating to unsworn falsification to authorities that:
1. Unless indicated by my checking the box next to a crime below, neither I nor any other
member of my household have been convicted or pled guilty or pled no contest or was
adjudicated delinquent where the record is publicly available pursuant to the Juvenile Act, 42
Pa.C.S. §6307 to any of the following crimes in Pennsylvania or a substantially equivalent crime
in any other jurisdiction, including pending charges:
Check
all that
apply
Crime
Self
Other
Household
Member
Date of
conviction,
guilty plea, no
contest plea or
pending charges
Sentence
( )
18 Pa.C.S. Ch.25
(relating to criminal
homicide)
( )
( )
______________
______
( )
18 Pa.C.S.§2702
( )
(relating to aggravated
assault)
( )
______________
______
( )
18 Pa.C.S.§2706
( )
(relating to terroristic
threats)
( )
______________
______
( )
18 Pa.C.S.§2709.1
( )
(relating to stalking)
( )
______________
______
( )
18 Pa.C.S.§2901
(relating to
kidnapping)
( )
( )
______________
______
( )
18 Pa.C.S.§2902
( )
(relating to unlawful
restraint)
( )
______________
______
( )
18 Pa.C.S.§2903
(relating to false
imprisonment)
( )
( )
______________
______
( )
18 Pa.C.S.§2910
( )
(relating to luring a
child into a motor
vehicle or structure)
( )
______________
______
( )
18 Pa.C.S.§3121
(relating to rape)
( )
( )
______________
______
( )
18 Pa.C.S.§3122.1
( )
(relating to statutory
sexual assault)
( )
______________
______
( )
18 Pa.C.S.§3123
( )
(relating to involuntary
deviate sexual intercourse)
( )
______________
______
( )
18 Pa.C.S.§3124.1
(relating to sexual
assault)
( )
( )
______________
______
( )
18 Pa.C.S.§3125
( )
(relating to aggravated
indecent assault)
( )
______________
______
( )
18 Pa.C.S.§3126
( )
(relating to indecent
assault)
18 Pa.C.S.§3127
( )
(relating to indecent
exposure)
( )
______________
______
( )
______________
______
( )
( )
18 Pa.C.S.§3129
( )
(relating to sexual
intercourse with animal)
( )
______________
______
( )
18 Pa.C.S.§3130
( )
(relating to conduct
relating to sex offenders)
( )
______________
______
( )
18 Pa.C.S.§3301
( )
(relating to arson and
related offenses)
( )
______________
______
( )
18 Pa.C.S.§4302
(relating to incest)
( )
( )
______________
______
( )
18 Pa.C.S.§4303
( )
(relating to concealing
death of child)
( )
______________
______
( )
18 Pa.C.S.§4304
( )
(relating to endangering
welfare of children)
( )
______________
______
( )
18 Pa.C.S.§4305
( )
(relating to dealing in
infant children)
( )
______________
______
( )
18 Pa.C.S.§5902(b) ( )
(relating to prostitution
and related offenses)
( )
______________
______
( )
18 Pa.C.S.§5903(c) ( )
or (d)
(relating to obscene and
other sexual materials
and performances)
( )
______________
______
( )
18 Pa.C.S.§6301
( )
(relating to corruption
of minors)
( )
______________
______
( )
18 Pa.C.S.§6312
(relating to sexual
abuse of children)
( )
______________
______
( )
( )
18 Pa.C.S.§6318
( )
(relating to unlawful
contact with minor)
( )
______________
______
( )
18 Pa.C.S.§6320
( )
(relating to sexual
exploitation of children)
( )
______________
______
( )
18 Pa.C.S.§6114
( )
(relating to contempt
for violation of
protection order or
agreement)
( )
______________
______
( )
Driving under the
influence of drugs
or alcohol
( )
( )
______________
______
( )
Manufacturing, sale, ( )
Delivery, holding
Offering for sale or
possession of any
controlled substance or
other drug or device
( )
______________
______
2. Unless indicated by my checking the box next to an item below, neither I nor any other
member of my household have a history of violent or abusive conduct including the following:
Check
all that
apply
Self
Other
Household
Member
Date
( )
A finding of abuse by a Children &
Youth Agency or similar agency in
Pennsylvania or similar statute in
another jurisdiction
( )
( )
________
( )
Abusive conduct as defined under the
( )
Protection from Abuse Act in Pennsylvania
or similar statute in another jurisdiction
Other: __________________________
( )
( )
________
( )
________
( )
3. Please list any evaluation, counseling or other treatment received following conviction or
finding of abuse: _______________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
4. If any conviction above applies to household member, not a party, state that person’s
name, date of birth and relationship to the child. ______________________________________
______________________________________________________________________________
_____________________________________________________________________________.
5. If you are aware that the other party or members of the other party’s household has or
have a criminal/abuse history, please explain: _________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
I verify that the information above is true and correct to the best of my knowledge,
information or belief. I understand that false statements herein are made subject to the penalties
of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities.
___________________________
Signature
____________________________
Printed Name
IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
___________________________________,
:
:
:
:
:
:
:
:
:
Plaintiff
vs.
,
Defendant
No.
VERIFICATION
I, _________________________, do hereby state, subject to the penalties of 18 Pa. C. S.
§ 4904 relating to unsworn falsification to authorities, that the facts set forth in the foregoing
Petition for Modification of Custody Order are true and correct to the best of my knowledge,
information, and belief.
DATE
__________________________________
Petitioner, Pro Se
IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW
__________________________________,
Plaintiff
vs.
__________________________________,
Defendant
:
:
:
:
:
:
:
:
:
No.
ORDER AND NOTICE
TO:
You, _________________________, Respondent, have been sued in court to modify (Shared
Legal Custody) (Sole Legal Custody) (Partial Physical Custody) (Primary Physical Custody)
(Shared Physical Custody) (Sole Physical Custody) (Supervised Physical Custody) of the
following child(ren): ___________________________________________________________
____________________________________________________________________________.
The Court has learned you may have a legal interest in custody of the child(ren) named.
A Conference will be scheduled by the Hearing Master.
If you wish to protect any legal interest you may have, or wish to present evidence to the
Court on those matters, you should appear at the place and time and on the date scheduled.
If you wish to claim the right of custody, or visitation, you may file a counterclaim.
If you fail to appear as provided by this Order, or to bring the child(ren), an order for
custody may be entered against you or the Court may issue a warrant for your arrest.
You must file with the Court a verification regarding any criminal record or abuse history
regarding you and anyone living in your household on or before the initial in-person contact with
the court (including, but not limited to, a conference with a conference officer or judge or
conciliation) but not later than 30 days after the service of the complaint or petition.
No party may make a change in the residence of any child which significantly impairs the
ability of the other party to exercise custodial rights without first complying with all of the
applicable provisions of 23 Pa.C.S. §5337 and Pa.R.C.P. No. 1915.17 regarding relocation.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF
YOU DO NOT HAVE OR KNOW A LAWYER, THEN YOU SHOULD GO TO OR
TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN
GET LEGAL HELP:
MERCER COUNTY LAWYERS’ REFERRAL SERVICE
c/o MERCER COUNTY BAR ASSOCIATION
P.O. BOX 1302
HERMITAGE, PENNSYLVANIA 16148
(724) 342-3111
AMERICANS WITH DISABILITIES’
ACT OF 1990
The Court of Common Pleas of Mercer County is required by law to comply
with the Americans and Disabilities Act of 1990. For information about accessible facilities
and reasonable accommodations available to disabled individuals having business before
the court, please contact our office. All arrangements must be made at least 72 hours prior
to any hearing or business before the court. You must attend the scheduled conference or
hearing.
BY THE COURT:
_________________________________J.
DATE: _____________________
IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
______________________________________________________________________________
__________________________________, :
Plaintiff
:
:
vs.
:
CIVIL ACTION NO.
:
_______________________________,
:
Defendant
:
______________________________________________________________________________
ORDER APPOINTING MASTER
IN ALL DOMESTIC RELATIONS ACTIONS EXCEPT PROTECTION FROM ABUSE
AND NOW, on this
day of
, 20____,
, is
hereby appointed Master with respect to the following claims:
()
In all claims involving martial property
()
Enforcement of marital agreements
()
Alimony and modification or termination thereof
()
Counsel fees and costs
()
Fault Divorces
()
Contested Divorces and Annulments
(X )
Preliminary Conferences only in custody cases
()
Bifurcation hearings
A conference shall be held in all matters except Protection from Abuse.
A Hearing ( ) Conference (X ) shall be conducted in the Master's Hearing Room,
Domestic Relations Office, North Courthouse Annex, Mercer, PA at a time and date to be
established by the Master.
2
If a Hearing is to be held, the parties shall be prepared to produce all of their evidence at
that time.
The Master shall make a report to this Court with a proposed Order, a copy of which shall
be furnished to the parties through their attorneys, or if no attorney by regular mail to the last
known address of the party. The Master's report shall contain a notice to the parties that within
ten days of the date of the report of the Master, any party may file exceptions to the report or any
part thereof to rulings on objections to evidence, to statements or findings of fact, conclusions of
law or to other matters occurring during the hearing. Notice shall also inform the parties that
matters not covered by exceptions are deemed waived unless, prior to entry of a final Order,
leave is granted to file exceptions raising these matters. If exceptions are filed, any other party
may file exceptions within ten days of the date of service of the original exceptions.
The Notice shall also state that if no exceptions are filed within the ten-day period, the
Court shall review the report and if approved, the Court will enter a final Order.
You are advised of your right to be represented by counsel throughout these proceedings.
BY THE COURT:
_________________________________, J.
DATE: _____________________
IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
,
Plaintiff
vs.
,
Defendant
:
:
:
:
:
:
:
:
CIVIL ACTION NO.
______________________________________________________________________________
CERTIFICATE OF SERVICE
I, ___________________________, hereby certify that I am this day serving a true and
correct copy of the foregoing pleading upon the following individual(s) in the manner described
below:
Service by United States Mail, Certified, Return Receipt Requested, addressed as
follows:
____________________________________________
____________________________________________
____________________________________________
Respectfully submitted:
By:
___________________________________
Plaintiff, Pro - Se
___________________________________
___________________________________
___________________________________
DATE: _______________________
IN THE COURT OF COMMON PLEAS OF MERCER COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
,
Plaintiff
vs.
,
Defendant
:
:
:
:
:
:
:
:
CIVIL ACTION NO.
______________________________________________________________________________
CRIMINAL RECORD / ABUSE HISTORY VERIFICATION
I, ________________________________, hereby swear or affirm, subject to penalties of
law including 18 Pa. C.S. §4904 relating to unsworn falsification to authorities that:
1. Unless indicated by my checking the box next to a crime below, neither I nor any other
member of my household have been convicted or pled guilty or pled no contest or was
adjudicated delinquent where the record is publicly available pursuant to the Juvenile Act, 42
Pa.C.S. §6307 to any of the following crimes in Pennsylvania or a substantially equivalent crime
in any other jurisdiction, including pending charges:
Check
all that
apply
Crime
Self
Other
Household
Member
Date of
conviction,
guilty plea, no
contest plea or
pending charges
Sentence
( )
18 Pa.C.S. Ch.25
(relating to criminal
homicide)
( )
( )
______________
______
( )
18 Pa.C.S.§2702
( )
(relating to aggravated
assault)
( )
______________
______
( )
18 Pa.C.S.§2706
( )
(relating to terroristic
threats)
( )
______________
______
( )
18 Pa.C.S.§2709.1
( )
(relating to stalking)
( )
______________
______
( )
18 Pa.C.S.§2901
(relating to
kidnapping)
( )
( )
______________
______
( )
18 Pa.C.S.§2902
( )
(relating to unlawful
restraint)
( )
______________
______
( )
18 Pa.C.S.§2903
(relating to false
imprisonment)
( )
( )
______________
______
( )
18 Pa.C.S.§2910
( )
(relating to luring a
child into a motor
vehicle or structure)
( )
______________
______
( )
18 Pa.C.S.§3121
(relating to rape)
( )
( )
______________
______
( )
18 Pa.C.S.§3122.1
( )
(relating to statutory
sexual assault)
( )
______________
______
( )
18 Pa.C.S.§3123
( )
(relating to involuntary
deviate sexual intercourse)
( )
______________
______
( )
18 Pa.C.S.§3124.1
(relating to sexual
assault)
( )
( )
______________
______
( )
18 Pa.C.S.§3125
( )
(relating to aggravated
indecent assault)
( )
______________
______
( )
18 Pa.C.S.§3126
( )
(relating to indecent
assault)
( )
______________
______
( )
18 Pa.C.S.§3127
( )
(relating to indecent
exposure)
( )
______________
______
( )
18 Pa.C.S.§3129
( )
(relating to sexual
intercourse with animal)
( )
______________
______
( )
18 Pa.C.S.§3130
( )
(relating to conduct
relating to sex offenders)
( )
______________
______
( )
18 Pa.C.S.§3301
( )
(relating to arson and
related offenses)
( )
______________
______
( )
18 Pa.C.S.§4302
(relating to incest)
( )
( )
______________
______
( )
18 Pa.C.S.§4303
( )
(relating to concealing
death of child)
( )
______________
______
( )
18 Pa.C.S.§4304
( )
(relating to endangering
welfare of children)
( )
______________
______
( )
18 Pa.C.S.§4305
( )
(relating to dealing in
infant children)
( )
______________
______
( )
18 Pa.C.S.§5902(b) ( )
(relating to prostitution
and related offenses)
( )
______________
______
( )
18 Pa.C.S.§5903(c) ( )
or (d)
(relating to obscene and
other sexual materials
and performances)
( )
______________
______
( )
18 Pa.C.S.§6301
( )
(relating to corruption
of minors)
( )
______________
______
( )
18 Pa.C.S.§6312
(relating to sexual
abuse of children)
( )
( )
______________
______
( )
18 Pa.C.S.§6318
( )
(relating to unlawful
contact with minor)
( )
______________
______
( )
18 Pa.C.S.§6320
( )
(relating to sexual
exploitation of children)
( )
______________
______
( )
18 Pa.C.S.§6114
( )
(relating to contempt
for violation of
protection order or
agreement)
( )
______________
______
( )
Driving under the
influence of drugs
or alcohol
( )
( )
______________
______
( )
Manufacturing, sale, ( )
Delivery, holding
Offering for sale or
possession of any
controlled substance or
other drug or device
( )
______________
______
2. Unless indicated by my checking the box next to an item below, neither I nor any other
member of my household have a history of violent or abusive conduct including the following:
Check
all that
apply
Self
Other
Household
Member
Date
( )
A finding of abuse by a Children &
Youth Agency or similar agency in
Pennsylvania or similar statute in
another jurisdiction
( )
( )
________
( )
Abusive conduct as defined under the
( )
Protection from Abuse Act in Pennsylvania
or similar statute in another jurisdiction
( )
________
( )
Other: __________________________
( )
( )
________
3. Please list any evaluation, counseling or other treatment received following conviction or
finding of abuse: _______________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
4. If any conviction above applies to household member, not a party, state that person’s
name, date of birth and relationship to the child. ______________________________________
______________________________________________________________________________
_____________________________________________________________________________.
5. If you are aware that the other party or members of the other party’s household has or
have a criminal/abuse history, please explain: _________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
I verify that the information above is true and correct to the best of my knowledge,
information or belief. I understand that false statements herein are made subject to the penalties
of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities.
___________________________
Signature
____________________________
Printed Name