Criminal Record/Abuse History Verification. Form 3
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1 Criminal Record/Abuse History Verification Form 3
2 CRIMINAL RECORD/ABUSE HISTORY VERIFICATION The following numbers on these instructions correspond with the numbers in the boxes on the Criminal Record/Abuse History Verification Form. Box 1: Box 2: Box 3: Box 4: Box 5: Print the county in which you are filing your custody action. See "Where do I File?" in the Introduction for more information about in which county you should file. Print plaintiff s name exactly as you wrote it on the other forms. Print the case number that has been assigned to your case. This can be found on your complaint or order. Print the defendant s name exactly as you wrote it on all other forms. Print your name. At Boxes 6 through 34 check each box that applies to you or a of your. the crime/abuse charge along with checking to whom it applies. Write the date of the plea and the sentence which was given. Re to answer each question completely. Box 35: Box 36: Box 37: Box 38: Box 39: List any evaluation, counseling or other treatment you or a of your received for any convictions listed above. If any convictions listed above apply to a not a party to this matter, state their name and relationship to the child(ren). If you know of a criminal history of the other party, or a of the other party s, state the information. Sign your name. Print your name. YOUR COMPLETED FORM MUST BE FILED WITH YOUR CUSTODY COMPLAINT. YOU MUST SEND A BLANK COPY OF THIS FORM TO THE OTHER PARTY WHEN YOU SERVE THE CUSTODY COMPLAINT. Criminal Record/Abuse History Verification Instructions
3 IN THE COURT OF COMMON PLEAS OF COUNTY, PENNSYLVANIA 1 2 : Plaintiff : : v. : 4 : : Defendant 3 No. IN CUSTODY CRIMINAL RECORD / ABUSE HISTORY VERIFICATION 5 I,, hereby swear or affirm, subject to penalties of law including 18 Pa.C.S 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 of my 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 to any of the following crimes in Pennsylvania or a substantially equivalent crime in any other jurisdiction, including pending : conviction, guilty plea or no contest plea, or pending 18 Pa.C.S. Ch. 25 (relating to criminal homicide) 18 Pa.C.S (relating to aggravated assault) 18 Pa.C.S (relating to terroristic threats) 1 Criminal Record/Abuse History Verification Instructions
4 conviction, guilty plea or no contest plea, or pending 18 Pa.C.S (relating to stalking) 18 Pa.C.S (relating to kidnapping) 18 Pa.C.S (relating to unlawful restraint) 18 Pa.C.S (relating to false imprisonment) 18 Pa.C.S (relating to luring a child into a motor vehicle or structure) 18 Pa.C.S (relating to rape) 18 Pa.C.S (relating to statutory sexual assault) 18 Pa.C.S (relating to involuntary deviate sexual intercourse) 18 Pa.C.S (relating to sexual assault) 18 Pa.C.S (relating to aggravated indecent assault) 18 Pa.C.S (relating to indecent assault) Criminal Record/Abuse History Verification Instructions 2
5 conviction, guilty plea or no contest plea, or pending 18 Pa.C.S (relating to indecent exposure) 18 Pa.C.S (relating to sexual intercourse with animal) 18 Pa.C.S (relating to conduct relating to sex offenders) 18 Pa.C.S (relating to arson and related offenses) 18 Pa.C.S (relating to incest) 18 Pa.C.S (relating to concealing death of child) 18 Pa.C.S (relating to endangering welfare of children) 18 Pa.C.S (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) 3 Criminal Record/Abuse History Verification Instructions
6 conviction, guilty plea or no contest plea, or pending 18 Pa.C.S (relating to corruption of minors) 18 Pa.C.S (relating to sexual abuse of children) 18 Pa.C.S (relating to unlawful contact with minor) 18 Pa.C.S (relating to sexual exploitation of children) 23 Pa.C.S (relating to contempt for violation of protection order or agreement) Driving under the influence of drugs or alcohol Manufacture, 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 of my have a history of violent or abusive conduct, or involvement with a Children & Youth Agency, including the following: apply Crime A finding of abuse by a Children & Youth Agency or similar agency in Pennsylvania or similar statute in another jurisdiction Self Household Member Date Criminal Record/Abuse History Verification Instructions 4
7 Abusive conduct as defined under the Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction. Involvement with Children & Youth or similar agency in Pennsylvania or another jurisdiction. Where?. : 3. Please list any evaluation, counseling or other treatment received following conviction or finding of abuse If any conviction above applies to a, not a party, state that person's name, date of birth, and relationship to the child If you are aware that the other party or s of the other party s has or have a criminal record/abuse history, please explain: 37 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 relating to unsworn falsification to authorities. 38 _ Signature 39 _ Printed Name Criminal Record/Abuse History Verification Instructions 5
8 IN THE COURT OF COMMON PLEAS OF COUNTY, PENNSYLVANIA : Plaintiff : : v. : No. : : CUSTODY Defendant CRIMINAL RECORD / ABUSE HISTORY VERIFICATION I,, hereby swear or affirm, subject to penalties of law including 18 Pa.C.S 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 of my 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 to any of the following crimes in Pennsylvania or a substantially equivalent crime in any other jurisdiction, including pending : conviction, guilty plea or no contest plea, or pending 18 Pa.C.S. Ch. 25 (relating to criminal homicide) 18 Pa.C.S (relating to aggravated assault) 18 Pa.C.S (relating to terroristic threats) 1 Criminal Record/Abuse History Verification Pa.R.C.P (c) AOPC
9 conviction, guilty plea or no contest plea, or pending 18 Pa.C.S (relating to stalking) 18 Pa.C.S (relating to kidnapping) 18 Pa.C.S (relating to unlawful restraint) 18 Pa.C.S (relating to false imprisonment) 18 Pa.C.S (relating to luring a child into a motor vehicle or structure) 18 Pa.C.S (relating to rape) 18 Pa.C.S (relating to statutory sexual assault) 18 Pa.C.S (relating to involuntary deviate sexual intercourse) 18 Pa.C.S (relating to sexual assault) 18 Pa.C.S (relating to aggravated indecent assault) 18 Pa.C.S (relating to indecent assault) 2 Criminal Record/Abuse History Verification Pa.R.C.P (c) AOPC
10 conviction, guilty plea or no contest plea, or pending 18 Pa.C.S (relating to indecent exposure) 18 Pa.C.S (relating to sexual intercourse with animal) 18 Pa.C.S (relating to conduct relating to sex offenders) 18 Pa.C.S (relating to arson and related offenses) 18 Pa.C.S (relating to incest) 18 Pa.C.S (relating to concealing death of child) 18 Pa.C.S (relating to endangering welfare of children) 18 Pa.C.S (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) Criminal Record/Abuse History Verification Pa.R.C.P (c) AOPC
11 Household Member conviction, guilty plea or no contest plea, or pending 18 Pa.C.S (relating to corruption of minors) 18 Pa.C.S (relating to sexual abuse of children) 18 Pa.C.S (relating to unlawful contact with minor) 18 Pa.C.S (relating to sexual exploitation of children) 23 Pa.C.S (relating to contempt for violation of protection order or agreement) Driving under the influence of drugs or alcohol Manufacture, 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 of my have a history of violent or abusive conduct or involvement with a Children & Youth Agency including the following: apply Self Household Member Date A finding of abuse by a Children & Youth Agency or similar agency in Pennsylvania or similar statute in another jurisdiction Criminal Record/Abuse History Verification Pa.R.C.P (c) AOPC
12 apply Self Household Member Date Abusive conduct as defined under the Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction. Involvement with Children & Youth or similar agency in Pennsylvania or another jurisdiction. Where?. : 3. Please list any evaluation, counseling or other treatment received following conviction or finding of abuse. 4. If any conviction above applies to a, 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 s of the other party s has or have a criminal record/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 relating to unsworn falsification to authorities. _ Signature Date: Printed Name Criminal Record/Abuse History Verification Pa.R.C.P (c) AOPC
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