FORM 3.2 Petition to Prevent Dissipation of Marital Assets

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT : IN DIVORCE

PETITION TO PREVENT DISSIPATION OF MARITAL ASSETS

Petitioner, Husband, files this Petition for Injunctive Relief, and is support thereof, avers as follows:

1. Petitioner is the plaintiff in the above-captioned divorce action.

2. Respondent is the defendant in the above-captioned divorce action.

3. Husband filed a Complaint in Divorce on __________________, 20______, requesting economic relief,

including a request for equitable distribution.

4. Husband has learned that Wife has redeemed Certificates of Deposit in the amount of $20,000 which are marital

property.

5. Based upon Wife's statements, Husband believes that Wife will either remove these funds from the

Commonwealth of Pennsylvania, spend the funds, or secret them in order to defeat his claim to an equitable distribution

of this marital property.

6. Husband further believes that Wife will dissipate, alienate or encumber other marital property of the parties.

7. Section 3323(f) of the Divorce Code provides in relevant part:

In all matrimonial causes, the court shall have full equity power and jurisdiction and may issue

injunctions or other orders which are necessary to protect the interests of the parties or to effectuate the

purposes of this part, and may grant such other relief or remedy as equity and justice require against

either party... .

8. Section 3505(a) of the Divorce Code provides:

Where it appears to the court that a party is about to leave the jurisdiction of the court or is about to

remove property of that party from the jurisdiction of the court or is about to dispose of, alienate or

encumber property in order to defeat equitable distribution, alimony pendente lite, alimony, child and

spousal support or a similar award, an injunction may issue to prevent the removal or disposition and the

property may be attached as prescribed by general rules.

9. Pennsylvania Rule of Civil Procedure 1920.43(a) provides:

At any time after the filing of the complaint, on petition setting forth the facts entitling the party to

relief, the court may, upon such terms and conditions as it deems just, including the filing of security,

(1) issue preliminary or special injunctions necessary to prevent the removal, disposition, alienation

or encumbering of real or personal property in accordance with Rule 1531(a), (c), (d) and (e); or

(2) order the seizure or attachment of real or personal property; or

(3) grant other appropriate relief.

WHEREFORE, Petitioner, Husband, respectfully requests that this Honorable Court grant the within

Petition for Injunctive Relief and enjoin and restrain Wife from encumbering, dissipating, selling or

otherwise alienating any and all marital assets of the parties.

Respectfully submitted,

__________________

Attorney for Husband

[Verification]

FORM 3.2A Order Restraining Dissipation of Marital Assets

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT : IN DIVORCE

ORDER

AND NOW, this __________________ day of __________________, 20______, upon consideration of the

__________________'s Petition for Injunctive Relief, it is hereby ORDERED and DECREED that

__________________ is hereby enjoined and restrained from encumbering, dissipating, selling or otherwise alienating

any and all marital assets of the parties, including but not limited to, the assets in the __________________ Pension

Plan, until further Order of the Court.

BY THE COURT:

__________________

FORM 3.3 Stipulation for Agreed Order (to Prevent Dissipation of Marital Property)

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT :

STIPULATION FOR AGREED ORDER

AND NOW, this __________________ day of __________________, 20______, the parties hereby stipulate and

agree that neither party shall sell, transfer, convey, assign, alienate, encumber, dissipate or otherwise transfer any

marital assets without the written consent of the other party or Court Order. The parties agree that this Stipulation shall

remain in effect until further written agreement of the parties or Order of the Court. This Stipulation is entered into

without prejudice to the parties' rights in the pending action. Nothing herein is intended to interfere with the daily

operations of __________________, Inc., the business owned and operated by __________________.

__________________

Plaintiff

__________________

Defendant

__________________

Plaintiff's Attorney

__________________

Defendant's Attorney

APPROVED BY THE

COURT:

__________________

FORM 3.4 Petition for Interim Exclusive Possession of Marital Residence

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT : IN DIVORCE

PETITION FOR INTERIM EXCLUSIVE POSSESSION OF MARITAL RESIDENCE PURSUANT TO §

3502(c) OF THE DIVORCE CODE

AND NOW, this __________________ day of __________________, 20______, Petitioner,

__________________, by and through his/her attorney, __________________, Esquire, files the within Petition for

Interim Exclusive Possession of Marital Residence, and in support thereof, avers as follows:

1. Petitioner is __________________, Plaintiff/Defendant in the above-captioned divorce action. Petitioner (and

the parties' children) reside at __________________ on a temporary basis.

2. Respondent is __________________, Defendant/Plaintiff in the above-captioned divorce action.

Plaintiff/Defendant currently resides at __________________, the ``marital home.''

3. The parties hereto were married on __________________, 20______, in __________________. The parties are

the parents of the following unemancipated children who reside with __________________ __________________: (1)

__________________ (born __________________); (2) __________________ (born __________________); (3) (born

__________________);

4. On __________________, 20______, __________________ filed a Complaint in Divorce against

__________________ in __________________ County, Pennsylvania.

5. The marital home, where the parties' children have resided exclusively since __________________, is owned by

the parties as tenants by the entireties.

6. Section 3502(c) of the Divorce Code states that ``the court may award, during the pendency of the action or

otherwise, to one or both of the parties the right to reside in the marital residence.''

7. Section 3323(f) of the Divorce Code states that ``[i]n all matrimonial causes, the court shall have full equity

power and jurisdiction and may issue injunctions or other orders which are necessary to protect the interests of the

parties or to effectuate the purposes of this part and may grant such other relief or remedy as equity and justice require

against either party or against any third person over whom the court has jurisdiction and who is involved in or

concerned with the disposition of the cause.''

8. The marital home is the only home the parties' children have ever known.

9. Unless Plaintiff/Defendant and the parties' children are permitted interim exclusive possession of the marital

home, the mental and emotional health and welfare of Plaintiff/Defendant and the children will be compromised.

10. Plaintiff/Defendant has been the primary caretaker and nurturer of the parties' children from the time of their

births to the present.

11. An award of interim exclusive possession of the marital home will avoid uprooting the parties' children from

not only the marital home, but also the social and community setting in which they were thriving.

12. Presently, Plaintiff/Defendant and the parties' children are living in an apartment located in an alien

environment which is further away from the children's school district, the family church, and the children's activities

(for soccer games, art lessons, etc.).

13. Moreover, the children are currently residing outside of their school district, and will not be able to attend their

respective schools unless they continue to reside within the school district.

14. Before Plaintiff/Defendant and the parties' children left the marital home on a temporary basis,

Plaintiff/Defendant engaged in a course of wrongful conduct which resulted in making the conditions under which

Plaintiff/Defendant and the parties' children were living both intolerable and unconscionable. Illustrations of such

conduct are the following:(a) __________________ was prohibited by __________________ from sleeping in her own

bed, thereby forcing __________________ to sleep on the floor.(b) On over __________________ occasions,

__________________ verbally abused and constantly nagged __________________ right before bedtime.(c) Before

__________________ left the marital home on a temporary basis, __________________ told __________________ on

a number of occasions to pack up her belongings and leave the marital home or __________________ would throw

__________________ __________________ out.(d) Before __________________ left the marital home on a

temporary basis, __________________ often directed vile and abusive language toward __________________ and the

children.(e) Before __________________ left the marital home on a temporary basis, __________________ neglected

his/her household and parental duties and obligations and ignored __________________ __________________ and the

children entirely.(f) Before __________________ left the marital home on a temporary basis, __________________

committed sexual excess which insulted __________________ sensibilities. (g) __________________'s aforesaid

conduct has had an adverse medical and emotional effect on __________________ and the children.(h) During the

parties' marriage, __________________ has engaged in open and flagrant marital misconduct, thereby subjecting

__________________ to an atmosphere of tension, stress and conflict.

WHEREFORE, Petitioner, __________________, respectfully requests this Honorable Court grant him/her and the

parties' children interim exclusive possession of the marital home until the conclusion of the divorce proceedings.

Respectfully submitted,

__________________

Attorney for Petitioner

[Verification]

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT : IN DIVORCE

ORDER

AND NOW, this __________________ day of __________________, 20______, upon consideration of the within

Petition for Interim Exclusive Possession of the Marital Residence filed by __________________, and after hearing

thereon, it is hereby ORDERED and DECREED that __________________ and the children are granted interim

exclusive possession of the marital residence located at __________________, and __________________ is hereby

ordered to vacate the property no later than __________________, __________________. M. on __________________,

20______. This order shall remain in effect until further order of the Court and is without prejudice to the issue of

possession and ownership of the home on a final basis as part of the equitable distribution proceedings.

BY THE COURT:

__________________

FORM 3.5 Petition to Stay Mortgage Foreclosure

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT : IN DIVORCE

PETITION TO STAY MORTGAGE FORECLOSURE

__________________, by and through his/her attorney, __________________, Esquire, files the within Petition to

Stay Mortgage Foreclosure, and in support thereof, avers as follows:

1. Petitioner is __________________, the plaintiff/defendant in the above-captioned divorce action.

2. Respondent is __________________, the plaintiff/defendant in the above-captioned divorce action.

3. __________________ has received a Notice of Intention to Foreclose from __________________ Bank stating

that the Bank intends to foreclose on the mortgage given by the parties with respect to the marital residence. Attached

hereto and made a part hereof as Exhibit ``A'' is a copy of the notice.

4. The marital residence is owned by the parties as tenants by the entireties and both parties signed the mortgage.

5. __________________ does not have the current ability to make the mortgage payments.

6. __________________ and the parties' children have been living in the marital residence for

__________________ years since the parties' separation.

7. __________________ and the parties' children would be emotionally harmed and injured if forced to vacate the

marital residence at this time.

8. __________________ has the financial ability to pay the mortgage and should be ordered to do so.

9. Section 3323(f) of the Divorce Code, as amended, permits this Honorable Court to enter an Order granting

special relief requested herein.

WHEREFORE, __________________ respectfully requests that this Honorable Court grant the within Petition to

Stay Mortgage Foreclosure and enter the following specific remedies:

1. Join __________________ Bank as a third-party defendant in the above-captioned action.

2. Stay any mortgage foreclosure proceedings instituted by __________________ Bank.

3. Order __________________ to pay the existing mortgage during the pendency of the divorce proceedings.

Respectfully submitted,

__________________

, Esquire

Attorney for

[Verification]

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT : IN DIVORCE

ORDER

AND NOW, this __________________ day of __________________, 20______, upon consideration of

__________________'s Petition to Stay Mortgage Foreclosure, and after hearing thereon, it is hereby ORDERED and

DECREED that:

1. __________________ Bank is joined as a third-party defendant in the above-captioned action.

2. __________________ Bank is stayed from foreclosing on the mortgage with __________________ and

__________________ until further Order of this Court.

3. __________________ shall pay the existing mortgage payment in the amount of $ ____________until further

Order of the Court.

BY THE COURT:

__________________

FORM 3.6 Petition for Interim Use of Personal Property

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT : IN DIVORCE

PETITION FOR INTERIM USE OF PERSONAL PROPERTY

Plaintiff/Defendant, by and through his/her attorney, __________________ __________________, Esquire, files

the within Petition for Interim Use of Personal Property, and in support thereof, avers as follows:

1. Petitioner is __________________, the Plaintiff/ Defendant and the Respondent is __________________ the

Defendant/Plaintiff in the above-captioned divorce action.

2. On __________________, 20______, the parties separated. __________________ left the marital home located

at __________________ __________________ and relocated to __________________.

3. __________________ and the parties' minor children now reside permanently at the __________________

address.

4. __________________ occupies the marital residence by [himself/herself] and currently enjoys the use of all of

the personal property therein.

5. __________________ will not permit __________________ to remove any of the personal property items.

6. Attached hereto and made a part hereof as Exhibit ``A'' is a reasonable listing of those items of personal property

which __________________ respectfully requests be used by him/her and their children pending final determination of

his/her economic claims.

WHEREFORE, Petitioner, __________________, respectfully requests that this Honorable Court grant the within

Petition for Interim Use of Personal Property.

Respectfully submitted,

__________________

, Esquire

Attorney for

[Verification]

EXHIBIT ``A''

LIBRARY

LIVING ROOM

DINING ROOM

KITCHEN

ENTRANCE HALL

MISCELLANEOUS

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT : IN DIVORCE

ORDER

AND NOW, this __________________ day of __________________, 20______, upon consideration of the

__________________ Petition for Interim Use of Personal Property, it is hereby ORDERED and DECREED that

__________________ shall return to __________________ the personal property listed on Exhibit ``A'' to this Order.

__________________ shall return these items to __________________ within twenty (20) days of the date of this

Court Order. This interim distribution of personal property is without prejudice to the final determination in equitable

distribution.

BY THE COURT:

__________________

FORM 3.7 Petition for Appointment of a Receiver

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT : IN DIVORCE

PETITION FOR APPOINTMENT OF A RECEIVER

__________________, by and through his/her attorney, __________________, Esquire, files the within Petition for

Appointment of a Receiver, and in support thereof, avers as follows:

1. Petitioner is __________________, the plaintiff/defendant in the above-captioned divorce action.

2. Respondent is __________________, the plaintiff/defendant in the above-captioned divorce action.

3. __________________ owns and operates __________________ __________________, Inc., the parties' closely

held family business.

4. __________________ owns 100% of the common stock of __________________, Inc.

5. __________________ acquired the stock during the marriage and the stock is marital property.

6. Although __________________ does not own any common stock titled in his/her name, __________________

has spent approximately __________________ hours per week for the last __________________

__________________ years working in the business without any pay.

7. __________________'s son/daughter is an employee of __________________, Inc. who has informed

__________________ that __________________ has removed $ ____________ from the corporate bank account

located at __________________ Bank and placed those funds in an account in his/her own name in a bank located

outside the Commonwealth of Pennsylvania.

8. __________________'s son/daughter has discovered that __________________ purchased a Porsche automobile

for $ ____________ with corporate funds and financed a trip to Puerto Rico costing $____________ with corporate

funds.

9. Due to this misappropriation of funds by __________________, __________________ can no longer be trusted

to manage the affairs of __________________, Inc. properly.

10. A receiver should be appointed to operate the business on a day-to-day basis during the pendency of the divorce

action.

11. Section 3505(a) of the Divorce Code, as amended, permits this Honorable Court to enter an Order granting the

special relief requested herein.

WHEREFORE, __________________ respectfully requests that this Honorable Court grant the within Petition for

Appointment of a Receiver.

Respectfully submitted,

__________________

, Esquire

Attorney for

[Verification]

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT :

IN DIVORCE

ORDER

AND NOW, this __________________ day of __________________, 20______, upon consideration of the within

Petition for Appointment of Receiver, and after hearing thereon, it is hereby ORDERED and DECREED that

__________________ is appointed as a receiver to operate __________________, Inc. during the pendency of the

divorce action. __________________ shall have all powers reasonably necessary to operate the business. This Order

shall remain in effect until further Order of this Court.

BY THE COURT:

__________________

FORM 3.8 Petition to Continue Insurance

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT : IN DIVORCE

PETITION TO CONTINUE INSURANCE

__________________, by and through his/her attorney, __________________, Esquire, files the within Petition to

Continue Insurance, and in support thereof, avers as follows:

1. Petitioner is __________________, the plaintiff/defendant in the above-captioned divorce action.

2. Respondent is __________________, the plaintiff/defendant in the above-captioned divorce action.

3. Prior to the parties' separation, __________________ had maintained policies insuring the life and health of

__________________ __________________.

4. These policies were originally purchased during the marriage and are in the effective control of

__________________.

5. __________________ has threatened to cancel his/her life insurance policy and receive the cash surrender value

of said policy.

6. __________________ has threatened to discontinue medical insurance for __________________ and the

children.

7. Said actions would be inappropriate in light of the intent of the Divorce Code.

8. The life insurance policy is with __________________ Insurance Company, policy number ____________, in

the amount of $____________.

9. The medical insurance policy is with __________________ Insurance Company, policy number ____________.

10. If __________________ has already terminated said policies, he/she should be required to obtain comparable

coverage.

11. Pursuant to Section 3502(d) the Court may:

Direct the continued maintenance and beneficiary designation of existing policies insuring the life or

health of either party which were originally purchased during the marriage and owned by or within the

effective control of either party. Where it is necessary to protect the interests of a party, the court may

also direct the purchase of, and the beneficiary designations on, a policy insuring the life or health of

either party.

12. Additional authority for entry of an order directing maintenance of health insurance is provided by 23 Pa.

C.S.A. § 4324, which provides that where a complaint for support or alimony pendent lite is pending, the Court may

direct one spouse to provide health care coverage to the other where the coverage is available as a benefit of

employment or at a reasonable cost, and by 23 Pa. C.S.A. § 4326, which mandates that health care coverage be provided

for children where it is available at reasonable cost.

WHEREFORE, __________________ respectfully requests that this Honorable Court grant the within Petition to

Continue Insurance.

Respectfully submitted,

__________________

, Esquire

Attorney for

[Verification]

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT : IN DIVORCE

ORDER

AND NOW, this __________________ day of __________________, 20______, upon consideration of the within

Petition to Continue Insurance, and after hearing thereon, it is hereby ORDERED and DECREED that

__________________ shall maintain the existing life and health insurance policies for the benefit of

__________________. The life insurance policy is with __________________ Insurance Company, policy number

____________, and the health insurance policy is with __________________ Insurance Company, policy number

____________ __________________. __________________ shall pay the premiums on these two policies during the

pendency of the divorce action. __________________ shall name __________________ as the sole beneficiary of the

life insurance policy. __________________ shall provide written documentation to __________________ that he/she

has paid the premiums each year and that he/she has designated __________________ as the sole beneficiary of the

said policy. __________________ shall cooperate in the submission of any insurance forms necessary to secure

payment of all insurance benefits to __________________. Plaintiff/Defendant shall not deposit any insurance checks

into any of his/her accounts but shall turn over all such checks to __________________ immediately and shall endorse

all such checks payable to __________________.

BY THE COURT:

__________________

FORM 3.9 Emergency Petition for Special Relief as to the Sale of Marital Residence to Prevent Foreclosure and

Interim Disposition of Personal Property

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT :

EMERGENCY PETITION FOR SPECIAL RELIEF AS TO THE SALE OF MARITAL RESIDENCE TO

PREVENT FORECLOSURE AND INTERIM DISPOSITION OF PERSONAL PROPERTY

1. Petitioner is __________________, the plaintiff/defendant in the above-captioned divorce action.

2. Respondent is __________________, the plaintiff/defendant in the above-captioned divorce action.

3. Petitioner and respondent were married on __________________, 20 ______, in __________________. During

the marriage, petitioner and respondent acquired a residence at __________________ (the ``marital residence''),

together with various items of personal property that are presently located in that residence.

4. Petitioner and respondent have been separated since __________________, 20 ______ [if relevant, explain

circumstances of separation, e.g., respondent moved into a separate bedroom in the marital residence; respondent forced

petitioner and their children to move out of the marital residence to live elsewhere].

5. Since separation, respondent has occupied and had exclusive possession of the marital residence.

6. Respondent, who has the financial ability to pay, has stopped paying the mortgage on the residence.

7. As a result, the mortgage is in default and may be subject to foreclosure, which would cause a dissipation of

marital assets.

8. The marital residence is a significant marital asset of the parties and, in order to protect the marital estate, the

marital residence must be sold before foreclosure occurs.

9. The marital residence should be listed for sale immediately, with the parties cooperating to accomplish the sale.

10. The net proceeds of the sale should be placed in escrow pending the final equitable distribution of the assets.

11. Until such time as the marital residence is sold, respondent, who has the financial ability to do so, should be

ordered to pay the monthly mortgage and expenses with respect to said property.

12. There are various items of personal property located in the marital residence which should be divided between

the parties on an interim basis without prejudice to the parties claims in the final equitable distribution of the assets.

13. Petitioner requests that respondent be enjoined from removing any item of personal property from the residence

until the interim distribution of personal property has been completed. Pending the interim distribution of personal

property in the marital residence, petitioner requests that respondent be enjoined from removing any item of personal

property from the residence.

WHEREFORE, Petitioner requests that this Court enter an Order granting the Emergency Petition for Special

Relief as to the Sale of Marital Residence to Prevent Foreclosure and Interim Disposition of Personal Property.

__________________

Attorney for Petitioner

[Verification]

FORM 3.10 Petition for Maintenance of Beneficiary Designations of Existing Life and Health Insurance Policies

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT :

PETITION FOR MAINTENANCE OF BENEFICIARY DESIGNATIONS OF EXISTING LIFE AND

HEALTH INSURANCE POLICIES

1. Petitioner is __________________, the Plaintiff/Defendant in the above-captioned divorce action.

2. Respondent is __________________, the Plaintiff/Defendant in the above-captioned divorce action.

COUNT I

3. Respondent is the owner of certain life insurance policies on his/her life of which Petitioner [or the children, if

applicable] is the beneficiary.

4. These policies were acquired during the marriage.

5. These policies are with [identify insurance companies and policy numbers].

6. Petitioner believes that Respondent may remove Petitioner [or the children, if applicable] as the beneficiary

thereof or will otherwise change the beneficiary designation so as to deprive Petitioner of the ability to receive death

benefits payable under said policy or policies in the event of Respondent's death. Petitioner requests that Respondent

maintain these policies without change of beneficiary designation, and pay any and all associated premiums on a timely

basis.

7. Respondent should be ordered to provide Petitioner with copies of the insurance policies, the beneficiary

designations, and evidence that the premiums have been paid.

COUNT II

8. Respondent has certain policies of health insurance under which Petitioner and the parties' children are covered.

9. Petitioner believes that Respondent may remove Petitioner and the children from said health insurance policies

which would have the effect of depriving them of health insurance benefits.

10. The health insurance coverage was acquired during the marriage.

11. Without the health insurance coverage, Petitioner and the children could be denied necessary medical care and

treatment or could be liable for substantial costs for such treatment.

12. Respondent should be ordered to maintain the health insurance policies for the benefit of Petitioner and the

children during the pendency of this action.

13. Respondent should pay any associated premiums for the coverage, and provide Petitioner with a copy of the

insurance policies, confirmation that the premiums have been paid, and any forms necessary to apply for coverage under

said policies.

14. Respondent should be ordered to cooperate and sign any documents necessary to provide the health insurance

coverage and benefits to Petitioner and the children.

__________________

Attorney for Petitioner

[Verification]

FORM 3.11 Petition for Allowance of Entry Upon Marital Property for a Physical Inspection and Appraisal

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT :

PETITION FOR ALLOWANCE OF ENTRY UPON MARITAL PROPERTY FOR A PHYSICAL

INSPECTION AND APPRAISAL

1. Petitioner is __________________, the Plaintiff/Defendant in the above-captioned divorce action.

2. Respondent is __________________, the Plaintiff/Defendant in the above-captioned divorce action.

3. Respondent is the owner of real estate and personal property which are marital property.

4. Respondent's assets are substantial in value and need to be appraised.

5. Petitioner requests allowance to inspect, measure, photograph, and/or videotape the premises.

6. Without the opportunity for Petitioner and/or his/her representative(s) to inspect and appraise the premises,

his/her ability to present fully the relevant testimony in the equitable distribution proceedings will be impaired.

WHEREFORE, Petitioner requests that this Court enter an Order granting the Petition for Allowance of Entry

Upon Marital Property for a Physical Inspection and Appraisal.

__________________

Attorney for Petitioner

[Verification]

FORM 3.12 Petition for Contribution to Expenses of the Marital Residence

IN THE COURT OF COMMON PLEAS

OF __________________, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT :

PETITION FOR CONTRIBUTION TO EXPENSES OF THE MARITAL RESIDENCE

1. Petitioner is __________________, the Plaintiff/Defendant in the above-captioned divorce action.

2. Respondent is __________________, the Plaintiff/Defendant in the above-captioned divorce action.

3. The parties acquired the marital residence located at __________________ during the marriage and said property

is marital property. The marital residence requires substantial expenditures for repairs and maintenance.

4. To date, Petitioner has been paying all of the costs associated with the marital residence and is providing the

necessary physical labor required for the maintenance of the property.

5. Petitioner has requested that Respondent share appropriately in the expenses of the property but Respondent has

failed and refused to do so.

6. Petitioner requests that Respondent be ordered to contribute financially to the costs associated with the marital

residence, both as to costs previously expended and those costs reasonably required in the future.

WHEREFORE, Petitioner requests that this Court enter an Order granting his/her Petition for Contribution to

Expenses of the Marital Residence.

__________________

Attorney for Petitioner

[Verification]

FORM 3.13 Petition for Joinder of Third Party

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT : IN DIVORCE

PETITION FOR JOINDER

1. Petitioner is __________________, the Plaintiff/Defendant in the above-captioned divorce action.

2. Respondent is __________________, the Plaintiff/Defendant in the above-captioned divorce action.

3. The parties' children are __________________, and __________________, (``the children'').

4. From the inception of the divorce action and continuing to date, Respondent has embarked on a series of

fraudulent and illegal transfers of property belonging to the marital estate to the children. These fraudulent transfers

include, but are not limited to, the following:a. The fraudulent and illegal transfer of the real estate located at

__________________ to the children on __________________ [date];b. The fraudulent and illegal transfer of

$____________ from __________________ Bank to the children on __________________ [date];c. The fraudulent

and illegal execution of [Name of legal document] allegedly transferring all of Respondent's assets to the children on

__________________ [date];d. The fraudulent and illegal transfer of $____________ from the Respondent's Pension

and Profit-Sharing Plan to the children.

5. Petitioner has good cause to believe that Respondent is now in the process of attempting to transfer the remainder

of the marital estate to the children to defeat Petitioner's claim for equitable distribution.

6. Petitioner has reason to believe that the children, intentionally or unknowingly, may be aiding and abetting

Respondent in an attempt to defeat Petitioner's claim for equitable distribution.

7. The children claim an interest in property which is the subject matter of the equitable distribution proceedings in

this case.

8. The children are indispensable parties to the equitable distribution proceedings.

9. The children should be joined as third-party defendants to the divorce action.

10. Section 3323(f) of the Divorce Code and Pennsylvania Rule of Civil Procedure 1920.34 permit this Honorable

Court to enter an Order granting the relief requested herein.

WHEREFORE, Petitioner requests that this Court enter an Order granting his/her Petition for Joinder.

__________________

Attorney for Petitioner

[Verification]

FORM 3.14 Petition for the Return of Personal Property

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT : IN DIVORCE

PETITION FOR THE RETURN OF PERSONAL PROPERTY

Petitioner, __________________, by and through his/her undersigned counsel, respectfully files the within Petition

for the Return of Personal Property, and in support thereof, avers as follows:

1. Petitioner is __________________, the plaintiff/defendant in the above-captioned divorce action.

2. Respondent is __________________, the plaintiff/defendant in the above-captioned divorce action.

3. The parties were married on __________________ and separated on __________________ when

__________________ left the marital residence located at __________________ and relocated to

__________________.

4. On __________________, __________________ filed a Complaint in Divorce asserting, inter alia, a claim for

equitable distribution.

5. On or about __________________, __________________ entered the marital residence while

__________________ was away and without his/her knowledge. At that time, __________________ surreptitiously

removed from the marital residence various items of personal property including [list specific items].

6. In order to maintain the status quo which has been in place since the date of separation until final distribution of

the marital property takes place, __________________ must be directed to return the personal property he/she removed

from the marital residence.

7. Pursuant to Sections 3323(f) and 3505(a) of the Divorce Code, 23 Pa. C.S. §§ 3323(f) and 3505(a), this Court is

empowered to enter an order requiring that the personal property removed from the marital residence be returned.

WHEREFORE, Petitioner, __________________, respectfully requests this Honorable Court enter an Order

granting his/her Petition for the Return of Personal Property.

Respectfully submitted,

__________________

, Esquire

Attorney for __________________

[Verification]

ORDER

AND NOW, this __________________ day of __________________, 20______, upon consideration of

__________________ Petition for Return of Personal Property, it is hereby ORDERED and DECREED that said

Petition is GRANTED. __________________ is directed to return to the marital residence within twenty (20) days of

the date of this Court Order, the following items of personal property: [list items]. It is further ordered that

__________________ is enjoined and restrained from removing any personal property from the marital residence until

further Order of this Court.

BY THE COURT:

__________________

FORM 3.15 Complaint for Specific Performance of Agreement and Other Legal and Equitable Relief

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT :

COMPLAINT FOR SPECIFIC PERFORMANCE OF AGREEMENT AND OTHER LEGAL AND

EQUITABLE RELIEF

Plaintiff, __________________, by and through her undersigned counsel, respectfully files this Complaint for

Specific Performance of Agreement and Other Legal and Equitable Relief and, in support thereof, avers as follows:

1. Plaintiff, __________________, is an adult individual residing at __________________.

2. Defendant, __________________, is an adult individual residing at __________________.

COUNT I PETITION TO ENFORCE AGREEMENT

3. In or about [date], the parties entered into an oral agreement to live together, to care for each other, and to

provide a comfortable home and living for each other, as more fully described in this Complaint.

4. Under the parties' agreement, Plaintiff agreed to provide food, lodging, clothing, medical care, laundry services,

and other caretaking services to Defendant.

5. Under the parties' agreement, Defendant promised Plaintiff that he would provide financially for Plaintiff for the

rest of his life, even after his death.

6. The parties lived together according to their agreement for [] years until they separated in [date].

7. Plaintiff, at all times, fulfilled her promise under the agreement by performing services for Defendant including,

but not limited to, shopping, preparing meals, doing laundry and nursing Defendant when he was ill.

8. From [date], Defendant regularly promised Plaintiff that he would care for her financially, that she need never

worry financially, and that he would take care of all of her financial concerns.

Page 31

9. From [date], Defendant paid for 100% of Plaintiff's living expenses, including, but not limited to, food, clothing,

housing, automobile, vacation and entertainment. Defendant also provided to Plaintiff free access to his credit cards.

10. Since separation, Defendant has revoked Plaintiff's charge card privileges and has limited her weekly cash

payment to $____________ per week.

11. Defendant's net worth is estimated to be in excess of $____________, due, in part, to Plaintiff's staunch support

and devotion to securing Defendant's happiness over their __________________ year relationship.

12. In reliance upon the parties' agreement to live together and to provide a comfortable home for each other,

Plaintiff declined to pursue her own career so that she is lacking marketable skills, is substantially unemployable, and

has no savings or pension to rely upon for support as she approaches age __________________. Plaintiff relied upon

Defendant as her sole source of financial support since [date], pursuant to the parties' agreement, which was reaffirmed

over and over again by Defendant.

WHEREFORE, Plaintiff requests that this Court specifically enforce Defendant's promise to support Plaintiff and

order Defendant to pay all of Plaintiff's expenses based upon their lifestyle developed over the years, for the rest of

Plaintiff's life, terminated only by cohabitation, marriage or Plaintiff's death, and order Defendant to make similar

provisions for Plaintiff's lifetime under his Will should Defendant predecease Plaintiff.

COUNT II PETITION FOR CONSTRUCTIVE TRUST

13. The allegations contained in the foregoing paragraphs are incorporated herein as if set forth in full.

14. Throughout the time that the parties lived together, they had a confidential relationship in which Plaintiff

believed that Defendant would always act in a manner consistent with her best interests.

15. Defendant abused such confidential relationship and took advantage of the trust of Plaintiff to obtain Plaintiff's

property and earnings in his own name or for his own benefit.

16. Defendant had no intention of furthering Plaintiff's financial best interests, but instead, deliberately

misrepresented his intentions to Defendant for the purpose of acquiring her savings, securities, and other assets which

provided to Plaintiff her only source of financial security.

17. Specifically, Defendant dissipated Plaintiff's __________________ Account No. ____________ with a value of

__________________ as of __________________.

18. Plaintiff did not authorize Defendant to manage her investment account.

19. Plaintiff is entitled to reimbursement for the losses that she sustained as a result of Defendant's unauthorized

trading of her stock through the imposition of a constructive trust in the amount of __________________, plus interest,

imposed upon Defendant's assets so as to avoid unjust enrichment.

WHEREFORE, Plaintiff respectfully requests that this Court enter an order directing that a constructive trust in the

amount of __________________, plus interest, be imposed upon Defendant's assets.

COUNT III PETITION FOR ENFORCEMENT OF AGREEMENT RELATING TO GIFTS

20. The allegations contained in the foregoing paragraphs are incorporated herein as if set forth in full.

21. Throughout their relationship, Defendant gifted to Plaintiff __________________ worth approximately

$____________.

22. Such gifts constitute Plaintiff's sole and exclusive property.

WHEREFORE, Plaintiff respectfully requests that this Court award to her sole ownership and exclusive possession

of said gifts.

Respectfully submitted,

__________________

, Esquire

Attorney for

[VERIFICATION]

FORM 4.3 Petition for Alimony Pendente Lite

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

RULE TO SHOW CAUSE

AND NOW, this __________________ day of __________________, 20______, upon consideration of the within

Petition for Court Order Awarding Alimony Pendente Lite, a RULE is granted upon Respondent to show cause why the

relief requested in said Petition should not be granted.

RULE RETURNABLE, with hearing thereon, on the __________________ day of __________________,

20______, at ____________ o'clock __________________ in Courtroom __________________, __________________

Courthouse, __________________, Pennsylvania.

BY THE COURT:

__________________

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

ORDER

AND NOW, this __________________ day of __________________, 20______, upon consideration of the within

Petition for Court Order Awarding alimony pendente lite and after hearing thereon, this Court Orders the Respondent to

make alimony pendente lite payments in the amount of $____________ per week beginning this __________________

day of __________________ __________________, 20______.

BY THE COURT:

__________________

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

PETITION FOR ALIMONY PENDENTE LITE

AND NOW, the Petitioner, __________________, by and through his/her attorney, __________________,

respectively represents the following:

1. A divorce proceeding between the Petitioner, __________________, and the Respondent,

__________________, was initiated on __________________.

2. The Petitioner is unable to sustain himself/herself during the course of litigation.

3. The Petitioner lacks sufficient property to provide for his/her reasonable needs and is unable to sustain

himself/herself through appropriate employment.

4. Plaintiff requests that this Court enter an award of alimony pendente lite until the final hearing and thereupon to

enter an award of alimony in his/her favor pursuant to Sections 3701(a) and 3702 of the 1980 Pennsylvania Divorce

Code.

WHEREFORE, Petitioner respectfully requests that this Court enter an award of alimony pendente lite until final

hearing and thereupon to enter an award of alimony in his/her favor pursuant to Sections 3701(a) and 3702 of the 1980

Pennsylvania Divorce Code, as amended.

Respectfully submitted,

__________________

, Esquire

Attorney for Petitioner

[Verification]

FORM 4.4 Income and Expense Statement

__________________ COUNTY, DOMESTIC RELATIONS SECTION

__________________ v. __________________ No. __________________

If you are self-employed or if you are salaried by a business of which you are the owner in whole or in part, you

must also fill out the Supplemental Income Statement which appears on the last page of this Income and Expense

Statement.

INCOME AND EXPENSE STATEMENT OF:

Name __________________

I verify that the statements made in this Income and Expense Statement are true and correct. I understand that false

statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 relating to the unsworn falsification to

authorities.

Date: ____________

__________________

Plaintiff or Defendant

INCOME

Employer __________________

Address __________________

Type of Work __________________

Payroll Number __________________

Pay Period (weekly, biweekly, etc.) __________________

Gross Pay per Pay $__________________

Period:

Itemized Payroll Deductions:

Federal Withholding $__________________

Social Security __________________

Local Wage Tax __________________

State Income Tax __________________

Retirement __________________

Savings Bonds __________________

Credit Union __________________

Life Insurance __________________

Health Insurance __________________

Other (specify)

__________________ __________________

Net Pay per Pay Period $__________________

Week Month Year

OTHER INCOME

(Fill in appropriate column)

Interest

$__________________

Dividends_____________________________________________________

Pension______________________________________________________

Annuity______________________________________________________

Social Security______________________________________________________

Rents______________________________________________________

Royalties______________________________________________________

ExpenseAccount ______________________________________

Gifts______________________________________________________

Unemployment Comp.______________________________________________________

Workers' Comp.______________________________________________________

________________________________________________________________________

TOTAL

$__________________

TOTAL INCOME $____________________________________

EXPENSES

Total Monthly

Self Spouse and/or Children

Home Mortgage/rent

$__________________

Maintenance______________________________________________________

Utilities______________________________________________________

Electric ______________________________________________________

Gas ______________________________________________________

Oil ______________________________________________________

Telephone ______________________________________________________

Water _____________________________________________________

Sewer ______________________________________________________

Employment

PublicTransportation______________________________________________________

Lunch______________________________________________________

Taxes Real Estate______________________________________________________

Personal Property______________________________________________________

Income______________________________________________________

Insurance

Homeowners______________________________________________________

Automobile______________________________________________

Life ______________________________________________________

Accident______________________________________________________

Health______________________________________________________

Other______________________________________________________

Automobile

Payments______________________________________________________

Fuel ______________________________________________________

Repairs______________________________________________________

Licenses/Registration______________________________________________________

AutoClub______________________________________________________

Medical

Doctor

__________

________

__________

________

__________________

Dent

ist

__________

________

__________

________

__________________

Orthod

ontist

__________

________

__________

________

__________________

Hospital

__________

________

__________

________

__________________

Med

icine

__________

________

__________

________

__________________

Special

Nee

(glas

__________

________

__________

________

__________________

ses,

brac

es,

orthop

edic

devi

ces)

Education

Priv

ate

Sch

ool

__________

________

__________

________

__________________

Parochial

Sch

ool

__________

________

__________

________

__________________

College

__________

________

__________

________

__________________

Religiou

__________

________

__________

________

__________________

Sch

ool

Lun

ches

__________

________

__________

________

__________________

Boo

ks/

Miscellane

ous

__________

________

__________

________

__________________

Personal

Clot

hing

__________

________

__________

________

__________________

Foo

__________

________

__________

________

__________________

Barb

er/

Hair

dres

ser

__________

________

__________

________

__________________

Person-

__________

________

__________

________

__________________

Care

Lau

ndry

/Dry

Clea

ning

__________

________

__________

________

__________________

Cred

Paymen

__________

________

__________

________

__________________

Credit Card __________

________

__________

________

__________________

Charge Account

__________

________

__________

________

__________________

mbe

rshi

__________

________

__________

________

__________________

Hob

bies

__________

________

__________

________

__________________

Loans or Debts

___

__________

________

__________

________

__________________

___

__________

________

__________

________

__________________

___

__________

________

__________

________

__________________

___

__________

________

__________

________

__________________

___

Miscellaneous

Hou

sehold

Help

__________

________

__________

________

__________________

Chil

Care

__________

________

__________

________

__________________

Cam

__________

________

__________

________

__________________

Pet

Expens

__________

________

__________

________

__________________

Papers/

Boo

ks/

Mag

azin

__________

________

__________

________

__________________

Entertainmen

__________

________

__________

________

__________________

Pay

__________

________

__________

________

__________________

Vacatio

__________

________

__________

________

__________________

Gift

__________

________

__________

________

__________________

Legal

Fees

__________

________

__________

________

__________________

Char

itable

Cont

ributions

__________

________

__________

________

__________________

Religiou

__________

________

__________

________

__________________

mbe

rshi

Chil

dren

Allowance

__________

________

__________

________

__________________

Other

Chil

Support

__________

________

__________

________

__________________

Alimon

Paymen

__________

________

__________

________

__________________

Other

___

__________

________

__________

________

__________________

___

__________

________

__________

________

__________________

___

__________

________

__________

________

__________________

___

__________

________

__________

________

__________________

___

TOT

EXPEN

SES

$_________

_________

$_________

_________

$__________________

__________

________

__________

________

__________________

__________________

PROPERTY OWNED Ownership*

Description Value HWJ

Real Estate

___________

_______

___________

_______

$__________

________

Mtg.

___________

_______

___________

_______

$__________

________

___________

_______

___________

_______

$__________

________

Mtg.

___________

_______

___________

_______

$__________

________

______

___________

_______

___________

_______

$__________

________

Mtg.

___________

_______

___________

_______

$__________

________

Bank Accounts

___________

_______

___________

_______

$__________

________

___________

_______

___________

_______

$__________

________

___________

_______

___________

_______

$__________

________

___________

_______

___________

_______

$__________

________

Securities

___________

_______

___________

_______

$__________

________

___________

_______

___________

_______

$__________

________

___________

_______

___________

_______

$__________

________

___________

_______

___________

_______

$__________

________

Automobiles

___________

_______

___________

_______

$__________

________

___________

_______

___________

_______

$__________

________

___________

_______

___________

_______

$__________

________

___________

_______

___________

_______

$__________

________

Other Assets

___________

_______

___________

_______

$__________

________

___________

_______

___________

_______

$__________

________

___________ ___________ $__________ ______

_______ _______ ________ __

___________

_______

___________

_______

$__________

________

TOTAL $_________________

__________________

INSURANCE

__________________

Coverage*

Company Policy No. HWC

Hospital ___________

_______

___________

_______

Medical ___________

_______

___________

_______

Health/Accident

___________

_______

___________

_______

Disability Income

___________

_______

___________

_______

Dental ___________

_______

___________

_______

Other ___________

_______

___________

_______

___________

_______

___________

_______

___________

_______

__________________

*H = Husband; W = Wife; J = Joint; C = Child.

SUPPLEMENTAL INCOME STATEMENT

(a) This form is to be filled out by a person (check one):______ (1) who operates a business or practices a

profession,

or______ (2) who is a member of a partnership or joint venture,

or______ (3) who is a shareholder in and is salaried by a closed corporation or similar entity.

(b) Attach to this statement a copy of the following documents relating to the partnership, joint venture, business,

profession, corporation or similar entity:

(1)the most recent Federal Income Tax Return, and

(2)the most recent Profit and Loss Statement.

Telephone Number __________________

(d) Nature of Business (check one)

__(1) partnership

__(2) joint venture

__(3) profession

__(4) closed corporation

__(5) other

(e) Name of accountant, controller or other person in charge of financial records: __________________

(f) Annual income from business: __________________(1) How often is income received?

__________________(2) Gross income per pay period: __________________(3) Net income per pay period:

__________________(4) Specified deductions, if any: __________________

FORM 4.5 Exceptions to Master's Recommendation (Record Proceeding)

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT : IN SUPPORT

PLAINTIFF'S EXCEPTIONS TO FINDINGS, RECOMMENDATIONS AND PROPOSED ORDER OF

SUPPORT OF THE PERMANENT HEARING OFFICER

Plaintiff, __________________, by his/her attorney, __________________ __________________, Esquire,

excepts to the Findings, Recommendations and Proposed Order of Support of the Honorable __________________,

Permanent Hearing Officer, dated __________________, 20______, as follows:

1. The Master erred in determining that Defendant's net monthly income is $__________________, in that the

Master ignored testimony given by the Defendant himself.

2. The Master erred [set forth specifics].

3. Plaintiff reserves the right to file additional exceptions after receipt of the transcript.

Respectfully submitted,

By:

__________________

Attorney for Plaintiff

cc: Attorney for Defendant

Permanent Hearing Officer

Official Court Reporter

FORM 4.6 Exceptions to Master's Recommendation (Nonrecord Proceeding)

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

EXCEPTIONS TO RECOMMENDATION OF THE CONCILIATOR IN:

__________________ SUPPORT __________________ EQUITABLE DISTRIBUTION __________________

CUSTODY

__________________, excepts to the recommendation of __________________ dated the __________________

day of __________________, 20______, and requests a hearing de novo.

I.D.

__________________

Counsel for:

I.D.

__________________

Counsel for:

__________________ __________________

__________________

ADDRESS

__________________

ADDRESS

ORDER

AND NOW, this __________________ day of __________________, 20______, exceptions having been filed to

the recommendation of __________________, and a request for a hearing de novo, a hearing is fixed for the

__________________ day of __________________, 20______, in Courtroom __________________ of the

__________________ County Courthouse at __________________ -. M.

BY THE COURT:

__________________

COURT ADMINISTRATOR

cc: Court Administrator

Domestic Relations

FORM 4.7 Stipulation for Agreed Order

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

STIPULATION FOR AGREED ORDER OF SUPPORT

AND NOW, this __________________ day of __________________, 20______, the Plaintiff,

__________________, and the Defendant, __________________, stipulate and agree as follows:

1. Defendant, __________________, will pay to the Domestic Relations Section of __________________ County,

in __________________, Pennsylvania, ($__________________) per __________________ for __________________

minor child(ren) and/or spouse, namely: __________________

__________________.

2. Defendant/Plaintiff is directed to provide medical coverage for __________________ through his/her employer

or a private carrier if available at a reasonable cost.

A mandatory wage attachment will be issued immediately unless: The Defendant is not in arrears in payment in an

amount equal to or greater than one month's support obligation and (1) one of the parties demonstrates, and the Court

finds, that there is good cause not to require immediate income withholding; or (2) a written agreement is reached

between the parties which provides for an alternate arrangement.

The parties will notify Domestic Relations Section in writing or by personal appearance within seven (7) days of

any change of employment, change of personal address or change of address of any child receiving support. Willful

failure to comply with this direction may cause a party to be adjudged in Contempt of Court.

On and after the date it is due, every support obligation shall constitute a judgment against the Defendant by

operation of law.

An automatic review of this Order may occur after three (3) years from the date of establishment of this Order or

upon the filing of a petition for modification by either party.

Arrearage balances may be reported to credit agencies.

The Plaintiff and Defendant, by signature below, request the Court to make an Order as indicated above, effective

the __________________ day of __________________, 20______.

__________________

Plaintiff

__________________

Witness

__________________

Defendant

__________________

Witness

FORM 4.8 Petition to Modify

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

ORDER OF COURT

You, __________________, Respondent, have been sued in Court to modify an existing support order. You are

ordered to appear in person at __________________ on __________________ at ____________.M., for a conference/

hearing and to remain until dismissed by the Court. If you fail to appear as provided in this Order, an Order for

Modification may be entered against you.

You are further ordered to bring to the conference:

(1)a true copy of your most recent Federal Income Tax Return, including W-2s, as filed,

(2)your pay stubs for the preceding six months,

(3)the Income and Expense Statement attached to this order, completed as required by Rule

1910.11(c),

(4)verification of child care expenses, and

(5)proof of medical coverage which you may have, or may have available to you.

THE APPROPRIATE COURT OFFICER MAY MODIFY OR TERMINATE THE EXISTING

ORDER IN ANY MANNER BASED UPON THE EVIDENCE PRESENTED.

Date of Order:____________

__________________

YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT

YOU. IF YOU DO NOT HAVE A LAWYER [OR CANNOT AFFORD ONE], GO TO OR TELEPHONE THE

OFFICE SET FORTH BELOW [TO FIND OUT WHERE YOU MAY GET LEGAL HELP]. 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.

__________________

(NAME)

__________________

(ADDRESS)

__________________

(TELEPHONE NUMBER)

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

PETITION FOR MODIFICATION OF [TO VACATE]

SUPPORT ORDER

The petition of __________________ respectfully represents:

1. Petitioner is __________________, who resides at __________________, and is employed by

__________________.

2. Respondent is __________________, who resides at __________________, and is employed by

__________________.

3. On the __________________ day of __________________, 20______, your Honorable Court entered an Order

against __________________ in the amount of $__________________ per week for the support of [spouse and/or

minor child(ren)]. A true and correct copy of the Order is marked Exhibit ``A'', attached hereto, and made a part hereof.

4. Petitioner is entitled to an [increase, decrease, modification, termination, suspension or vacation] of this Order

because of the following material and substantial change[s] in circumstance[s]: [state changes]. A true and correct copy

of the Order is marked Exhibit ``A,'' attached hereto, and made a part hereof.''

WHEREFORE, Petitioner requests that the Court [increase, decrease, modify, terminate, suspend or vacate] the

existing order for support [and medical coverage and award filing fees, reasonable attorney fees, necessary travel

expenses and other reasonable expenses incurred by Petitioner and Petitioner's witnesses].

By:

__________________

, Esquire

Counsel for Petitioner

[Verification]

FORM 4.8A Monthly Basic Child Support Schedule-Support Guidelines

The following schedule sets forth the amounts spent on children in intact families by combined income and number

of children. Combined income is on the vertical axis of the schedule and number of children is on the horizontal axis of

the schedule. This schedule is used to find the basic child support obligation. Unless otherwise provided in these rules,

the obligor's share of the basic support obligation shall be computed using the formula set forth in Part I of Rule

1910.16-4.

COMBINED

ADJUSTED

NET

INCOME

ONE

CHIL

TWO

CHIL

DRE

THR

CHIL

DRE

FOU

CHIL

DRE

FIVE

CHIL

DRE

SIX

CHILDREN

0-800 50 50 50 50 50 50

850 92 93 94 95 96 97

900 137 138 140 141 143 144

950 182 184 186 188 190 192

1000 227 229 232 234 237 239

1050 271 275 278 281 284 287

1100 284 320 324 327 331 334

1150 296 366 370 374 378 382

1200 309 411 416 420 425 429

1250 322 455 462 467 472 477

1300 335 472 508 513 519 524

1350 348 490 554 560 566 572

1400 360 508 589 606 613 619

1450 373 526 610 653 660 667

1500 386 544 630 699 707 714

1550 397 560 648 723 754 762

1600 409 575 666 743 801 809

1650 421 591 684 763 839 857

1700 432 607 702 783 861 904

1750 444 623 720 803 883 952

1800 455 638 738 822 905 984

1850 467 654 756 842 927 1008

1900 479 670 773 862 949 1032

1950 490 685 790 881 969 1055

2000 501 700 807 900 990 1077

2050 512 715 824 918 1010 1099

2100 523 729 840 937 1031 1121

2150 534 744 857 955 1051 1143

2200 545 759 873 974 1071 1166

2250 557 774 890 992 1092 1188

2300 568 789 907 1011 1112 1210

2350 579 804 924 1030 1133 1233

2400 591 820 942 1051 1156 1257

2450 603 837 961 1071 1179 1282

2500 615 853 979 1092 1201 1307

2550 626 869 998 1113 1224 1332

2600 638 886 1017 1134 1247 1357

2650 650 902 1035 1154 1270 1381

2700 662 918 1054 1175 1292 1406

2750 674 935 1072 1196 1315 1431

2800 684 949 1088 1213 1335 1452

2850 694 962 1103 1230 1353 1472

2900 704 976 1118 1246 1371 1492

2950 714 989 1133 1263 1389 1511

3000 724 1003 1147 1279 1407 1531

3050 734 1016 1162 1296 1425 1551

3100 744 1029 1177 1312 1443 1570

3150 754 1043 1192 1329 1461 1590

3200 763 1054 1204 1342 1477 1607

3250 767 1059 1207 1346 1481 1611

3300 772 1063 1211 1350 1485 1616

3350 776 1068 1214 1354 1489 1620

3400 781 1072 1218 1358 1494 1625

3450 785 1077 1221 1362 1498 1630

3500 790 1081 1225 1365 1502 1634

3550 794 1086 1228 1369 1506 1639

3600 798 1090 1231 1373 1510 1643

3650 804 1096 1237 1380 1518 1651

3700 809 1103 1245 1388 1526 1661

3750 815 1110 1252 1396 1535 1670

3800 820 1117 1259 1403 1544 1680

3850 826 1123 1266 1411 1552 1689

3900 831 1130 1273 1419 1561 1699

3950 837 1137 1280 1427 1570 1708

4000 843 1144 1287 1435 1579 1717

4050 848 1151 1294 1443 1587 1727

4100 854 1158 1302 1452 1597 1738

4150 860 1165 1310 1461 1607 1748

4200 866 1173 1318 1469 1616 1759

4250 872 1180 1326 1478 1626 1769

4300 878 1187 1334 1487 1636 1780

4350 884 1194 1341 1496 1645 1790

4400 890 1202 1349 1504 1655 1800

4450 896 1209 1357 1513 1665 1811

4500 902 1216 1365 1522 1674 1821

4550 908 1224 1373 1531 1684 1832

4600 914 1231 1381 1539 1693 1842

4650 920 1238 1389 1548 1703 1853

4700 924 1243 1394 1554 1709 1860

4750 925 1245 1395 1555 1711 1861

4800 927 1246 1396 1557 1713 1863

4850 928 1248 1398 1558 1714 1865

4900 930 1249 1399 1560 1716 1867

4950 931 1251 1400 1561 1717 1869

5000 933 1253 1402 1563 1719 1870

5050 934 1254 1403 1564 1721 1872

5100 936 1256 1404 1566 1722 1874

5150 937 1257 1406 1567 1724 1876

5200 939 1259 1407 1569 1726 1877

5250 940 1261 1408 1570 1727 1879

5300 942 1262 1410 1572 1729 1881

5350 943 1264 1411 1573 1731 1883

5400 945 1265 1412 1575 1732 1885

5450 946 1267 1414 1576 1734 1886

5500 948 1268 1415 1578 1735 1888

5550 952 1273 1420 1583 1742 1895

5600 959 1283 1431 1595 1755 1909

5650 966 1292 1441 1607 1768 1923

5700 973 1302 1452 1619 1780 1937

5750 980 1312 1462 1630 1793 1951

5800 988 1321 1473 1642 1806 1965

5850 995 1331 1483 1654 1819 1979

5900 1002 1340 1494 1666 1832 1993

5950 1009 1350 1504 1677 1845 2007

6000 1016 1359 1515 1689 1858 2021

6050 1023 1369 1525 1701 1871 2035

6100 1030 1379 1536 1712 1884 2049

6150 1038 1388 1546 1724 1897 2063

6200 1045 1398 1557 1736 1909 2077

6250 1052 1407 1567 1748 1922 2092

6300 1059 1417 1578 1759 1935 2106

6350 1066 1426 1588 1771 1948 2120

6400 1072 1435 1597 1781 1959 2132

6450 1077 1441 1604 1788 1967 2140

6500 1082 1447 1610 1796 1975 2149

6550 1087 1454 1617 1803 1983 2158

6600 1092 1460 1624 1810 1991 2167

6650 1097 1466 1630 1818 1999 2175

6700 1102 1473 1637 1825 2008 2184

6750 1107 1479 1643 1832 2016 2193

6800 1112 1485 1650 1840 2024 2202

6850 1117 1491 1657 1847 2032 2211

6900 1122 1498 1663 1854 2040 2219

6950 1127 1504 1670 1862 2048 2228

7000 1132 1510 1676 1869 2056 2237

7050 1137 1517 1683 1876 2064 2246

7100 1142 1523 1690 1884 2072 2255

7150 1147 1529 1696 1891 2080 2263

7200 1152 1536 1703 1898 2088 2272

7250 1157 1542 1709 1906 2096 2281

7300 1162 1548 1716 1913 2104 2290

7350 1167 1555 1722 1921 2113 2298

7400 1172 1561 1729 1928 2121 2307

7450 1177 1567 1736 1935 2129 2316

7500 1182 1573 1742 1943 2137 2325

7550 1187 1580 1749 1950 2145 2334

7600 1192 1586 1755 1957 2153 2342

7650 1197 1592 1762 1965 2161 2351

7700 1202 1598 1768 1971 2169 2359

7750 1206 1604 1774 1978 2176 2367

7800 1210 1609 1780 1985 2183 2375

7850 1214 1615 1786 1992 2191 2384

7900 1219 1620 1792 1998 2198 2392

7950 1223 1626 1798 2005 2206 2400

8000 1227 1631 1804 2012 2213 2408

8050 1231 1637 1810 2019 2220 2416

8100 1235 1642 1816 2025 2228 2424

8150 1240 1648 1822 2032 2235 2432

8200 1244 1653 1828 2039 2243 2440

8250 1248 1659 1835 2045 2250 2448

8300 1252 1664 1841 2052 2257 2456

8350 1257 1670 1847 2059 2265 2464

8400 1261 1675 1853 2066 2272 2472

8450 1265 1681 1859 2072 2280 2480

8500 1269 1686 1865 2079 2287 2488

8550 1273 1692 1871 2086 2295 2496

8600 1278 1697 1877 2093 2302 2504

8650 1282 1703 1883 2099 2309 2513

8700 1286 1708 1889 2106 2317 2521

8750 1290 1714 1895 2113 2324 2529

8800 1295 1719 1901 2120 2332 2537

8850 1299 1725 1907 2126 2339 2545

8900 1303 1730 1913 2133 2346 2553

8950 1307 1736 1919 2140 2354 2561

9000 1311 1741 1925 2147 2361 2569

9050 1316 1747 1931 2153 2369 2577

9100 1320 1752 1937 2160 2376 2585

9150 1324 1758 1943 2167 2383 2593

9200 1328 1763 1949 2173 2391 2601

9250 1333 1769 1955 2180 2398 2609

9300 1337 1775 1961 2187 2406 2617

9350 1341 1780 1967 2194 2413 2625

9400 1345 1786 1973 2200 2420 2633

9450 1349 1791 1980 2207 2428 2642

9500 1354 1797 1986 2214 2435 2650

9550 1358 1802 1992 2221 2443 2658

9600 1362 1807 1996 2226 2449 2664

9650 1365 1811 2001 2231 2454 2670

9700 1369 1815 2005 2235 2459 2675

9750 1372 1819 2009 2240 2464 2681

9800 1376 1823 2013 2244 2469 2686

9850 1379 1827 2017 2249 2474 2692

9900 1383 1832 2021 2253 2479 2697

9950 1386 1836 2025 2258 2484 2702

10000 1390 1840 2029 2263 2489 2708

10050 1393 1844 2033 2267 2494 2713

10100 1397 1848 2037 2272 2499 2719

10150 1400 1852 2042 2276 2504 2724

10200 1404 1856 2046 2281 2509 2730

10250 1407 1860 2050 2285 2514 2735

10300 1411 1865 2054 2290 2519 2741

10350 1414 1869 2058 2295 2524 2746

10400 1418 1873 2062 2299 2529 2752

10450 1421 1877 2066 2304 2534 2757

10500 1425 1881 2070 2308 2539 2763

10550 1428 1885 2074 2313 2544 2768

10600 1432 1889 2078 2317 2549 2774

10650 1435 1894 2083 2322 2554 2779

10700 1439 1898 2087 2327 2559 2784

10750 1442 1902 2091 2331 2564 2790

10800 1446 1906 2095 2336 2569 2795

10850 1449 1910 2099 2340 2574 2801

10900 1453 1914 2103 2345 2579 2806

10950 1456 1918 2107 2349 2584 2812

11000 1460 1922 2111 2354 2589 2817

11050 1464 1927 2115 2359 2594 2823

11100 1467 1931 2119 2363 2599 2828

11150 1471 1935 2124 2368 2604 2834

11200 1474 1939 2128 2372 2610 2839

11250 1478 1943 2132 2377 2615 2845

11300 1481 1947 2136 2381 2620 2850

11350 1485 1951 2140 2386 2625 2856

11400 1488 1956 2144 2391 2630 2861

11450 1492 1960 2148 2395 2635 2866

11500 1495 1964 2152 2400 2640 2872

11550 1499 1968 2156 2404 2645 2877

11600 1502 1972 2160 2409 2650 2883

11650 1506 1976 2164 2413 2655 2888

11700 1509 1980 2169 2418 2660 2894

11750 1513 1984 2173 2423 2665 2899

11800 1516 1989 2177 2427 2670 2905

11850 1520 1993 2181 2432 2675 2910

11900 1523 1997 2185 2436 2680 2916

11950 1527 2001 2189 2441 2685 2921

12000 1530 2005 2193 2445 2690 2927

12050 1534 2009 2197 2450 2695 2932

12100 1537 2013 2201 2455 2700 2938

12150 1541 2018 2205 2459 2705 2943

12200 1544 2022 2210 2464 2710 2948

12250 1548 2026 2214 2468 2715 2954

12300 1551 2030 2218 2473 2720 2959

12350 1555 2034 2222 2477 2725 2965

12400 1558 2038 2226 2482 2730 2970

12450 1562 2042 2230 2486 2735 2976

12500 1565 2046 2234 2491 2740 2981

12550 1569 2051 2238 2496 2745 2987

12600 1572 2055 2242 2500 2750 2992

12650 1576 2059 2246 2505 2755 2998

12700 1579 2063 2251 2509 2760 3003

12750 1583 2067 2255 2514 2765 3009

12800 1586 2071 2259 2518 2770 3014

12850 1590 2075 2263 2523 2775 3020

12900 1593 2080 2267 2528 2780 3025

12950 1597 2084 2271 2532 2785 3030

13000 1600 2088 2275 2537 2790 3036

13050 1604 2092 2279 2541 2795 3041

13100 1607 2096 2283 2546 2800 3047

13150 1611 2100 2287 2550 2805 3052

13200 1614 2104 2291 2555 2811 3058

13250 1618 2108 2296 2560 2816 3063

13300 1622 2113 2300 2564 2821 3069

13350 1625 2117 2304 2569 2826 3074

13400 1629 2121 2308 2573 2831 3080

13450 1632 2125 2312 2578 2836 3085

13500 1636 2129 2316 2582 2841 3091

13550 1639 2133 2320 2587 2846 3096

13600 1643 2137 2324 2592 2851 3102

13650 1646 2142 2328 2596 2856 3107

13700 1650 2146 2332 2601 2861 3113

13750 1653 2150 2337 2605 2866 3118

13800 1657 2154 2341 2610 2871 3123

13850 1660 2158 2345 2614 2876 3129

13900 1664 2162 2349 2619 2881 3134

13950 1667 2166 2353 2624 2886 3140

14000 1671 2170 2357 2628 2891 3145

14050 1674 2175 2361 2633 2896 3151

14100 1678 2179 2365 2637 2901 3156

14150 1681 2183 2369 2642 2906 3162

14200 1685 2187 2373 2646 2911 3167

14250 1688 2191 2378 2651 2916 3173

14300 1692 2195 2382 2656 2921 3178

14350 1695 2199 2386 2660 2926 3184

14400 1699 2203 2390 2665 2931 3189

14450 1702 2208 2394 2669 2936 3195

14500 1706 2212 2398 2674 2941 3200

14550 1709 2216 2402 2678 2946 3205

14600 1713 2220 2406 2683 2951 3211

14650 1716 2224 2410 2687 2956 3216

14700 1720 2228 2414 2692 2961 3222

14750 1723 2232 2418 2697 2966 3227

14800 1727 2237 2423 2701 2971 3233

14850 1730 2241 2427 2706 2976 3238

14900 1734 2245 2431 2710 2981 3244

14950 1737 2249 2435 2715 2986 3249

15000 1741 2253 2439 2719 2991 3255

15050 1806 2319 2493 2780 3058 3327

15100 1811 2325 2498 2785 3064 3334

15150 1816 2330 2503 2791 3071 3341

15200 1821 2336 2509 2797 3077 3348

15250 1826 2342 2514 2803 3084 3355

15300 1831 2347 2519 2809 3090 3362

15350 1836 2353 2525 2815 3097 3369

15400 1841 2359 2530 2821 3103 3376

15450 1846 2364 2535 2827 3110 3383

15500 1851 2370 2541 2833 3116 3390

15550 1856 2375 2546 2839 3123 3397

15600 1861 2381 2551 2845 3129 3404

15650 1866 2387 2557 2851 3136 3411

15700 1871 2392 2562 2856 3142 3419

15750 1876 2398 2567 2862 3149 3426

15800 1881 2404 2572 2868 3155 3433

15850 1886 2409 2578 2874 3162 3440

15900 1891 2415 2583 2880 3168 3447

15950 1896 2420 2588 2886 3175 3454

16000 1901 2426 2594 2892 3181 3461

16050 1906 2432 2599 2898 3188 3468

16100 1911 2437 2604 2904 3194 3475

16150 1916 2443 2610 2910 3201 3482

16200 1921 2449 2615 2916 3207 3489

16250 1926 2454 2620 2921 3214 3496

16300 1931 2460 2625 2927 3220 3503

16350 1936 2466 2631 2933 3227 3511

16400 1941 2471 2636 2939 3233 3518

16450 1946 2477 2641 2945 3240 3525

16500 1951 2482 2647 2951 3246 3532

16550 1956 2488 2652 2957 3253 3539

16600 1961 2494 2657 2963 3259 3546

16650 1966 2499 2663 2969 3266 3553

16700 1971 2505 2668 2975 3272 3560

16750 1976 2511 2673 2981 3279 3567

16800 1981 2516 2678 2986 3285 3574

16850 1986 2522 2684 2992 3292 3581

16900 1991 2527 2689 2998 3298 3588

16950 1996 2533 2694 3004 3305 3595

17000 2001 2539 2700 3010 3311 3603

17050 2006 2544 2705 3016 3318 3610

17100 2011 2550 2710 3022 3324 3617

17150 2016 2556 2716 3028 3331 3624

17200 2021 2561 2721 3034 3337 3631

17250 2026 2567 2726 3040 3344 3638

17300 2031 2572 2731 3046 3350 3645

17350 2036 2578 2737 3052 3357 3652

17400 2041 2584 2742 3057 3363 3659

17450 2046 2589 2747 3063 3370 3666

17500 2051 2595 2753 3069 3376 3673

17550 2056 2601 2758 3075 3383 3680

17600 2061 2606 2763 3081 3389 3687

17650 2066 2612 2769 3087 3396 3694

17700 2071 2618 2774 3093 3402 3702

17750 2076 2623 2779 3099 3409 3709

17800 2081 2629 2784 3105 3415 3716

17850 2086 2634 2790 3111 3422 3723

17900 2091 2640 2795 3117 3428 3730

17950 2096 2646 2800 3122 3435 3737

18000 2101 2651 2806 3128 3441 3744

18050 2106 2657 2811 3134 3448 3751

18100 2111 2663 2816 3140 3454 3758

18150 2116 2668 2822 3146 3461 3765

18200 2121 2674 2827 3152 3467 3772

18250 2126 2679 2832 3158 3474 3779

18300 2131 2685 2838 3164 3480 3786

18350 2136 2691 2843 3170 3487 3794

18400 2141 2696 2848 3176 3493 3801

18450 2146 2702 2853 3182 3500 3808

18500 2151 2708 2859 3187 3506 3815

18550 2156 2713 2864 3193 3513 3822

18600 2161 2719 2869 3199 3519 3829

18650 2166 2725 2875 3205 3526 3836

18700 2171 2730 2880 3211 3532 3843

18750 2176 2736 2885 3217 3539 3850

18800 2181 2741 2891 3223 3545 3857

18850 2186 2747 2896 3229 3552 3864

18900 2191 2753 2901 3235 3558 3871

18950 2196 2758 2906 3241 3565 3878

19000 2201 2764 2912 3247 3571 3886

19050 2206 2770 2917 3253 3578 3893

19100 2211 2775 2922 3258 3584 3900

19150 2216 2781 2928 3264 3591 3907

19200 2221 2786 2933 3270 3597 3914

19250 2226 2792 2938 3276 3604 3921

19300 2231 2798 2944 3282 3610 3928

19350 2236 2803 2949 3288 3617 3935

19400 2241 2809 2954 3294 3623 3942

19450 2246 2815 2959 3300 3630 3949

19500 2251 2820 2965 3306 3636 3956

19550 2256 2826 2970 3312 3643 3963

19600 2261 2831 2975 3318 3649 3970

19650 2266 2837 2981 3323 3656 3977

19700 2271 2843 2986 3329 3662 3985

19750 2276 2848 2991 3335 3669 3992

19800 2281 2854 2997 3341 3675 3999

19850 2286 2860 3002 3347 3682 4006

19900 2291 2865 3007 3353 3688 4013

19950 2296 2871 3012 3359 3695 4020

20000 2301 2877 3018 3365 3701 4027

FORM 4.9 Support Guideline Computation Chart

PART I. BASIC CHILD SUPPORT

OBLIGOR

OBLIGEE

1. Total Gross Income

per Pay Period

________

__________

________

2. Less Deductions (________

________

__)

(_________

_________)

3. Net income ________

________

__________

________

4. Conversion to

Monthly Amount (if

pay period is other

than monthly)

__________

________

5. Combined Total

Monthly Net Income

__________________

6. BASIC CHILD

SUPPORT OBLIGATION

(Determine either

from Schedule based

on number of children

and line 5 combined

monthly net

income OR from

Chart by finding proportion

of combined

income spent on the

children)

__________________

7. Net Income Ex- ________ __________

pressed as a Percentage

Share of Income

(Divide line 4 by line

5 and multiply by

100)

________

8. Each Parent's

Monthly Share of the

Basic Child Support

Obligation (Multiply

line 6 by line 7)

________

__________

________

PART II. SUBSTANTIAL or SHARED PHYSICAL CUSTODY ADJUSTMENT, IF APPLICANT (See

subdivision (c) of this Rule)

9. (a) Percentage of Time

Spent with Children

(Divide number of

overnights with obligor

by 365 and multiply by

100)

____________

______%

(b) Subtract 30% ____________

______%

Share of the

Basic Monthly Support

Obligation (Subtract

line 9b from line 7)

____________

______%

(d) Obligor's Adjusted

Share of the Basic

Monthly Support Obligation

(Multiply line 9c

by line 6)

____________

______

(e) Further adjustment, if

necessary, under subdivision

(c)(2) of this

Rule

____________

______

PART III. ADDITIONAL EXPENSES (See Rule 1910.16-6)

10. (a) Obligor's share of child care expenses

(b) Obligor's share of

health insurance premium,

if obligee is paying

the premium

____________

______

the health insurance

premium, if obligor is

(___________

_______)

paying the premium

(d) Obligor's share of unreimbursed

medical expenses

____________

______

(e) Other additional expenses

____________

______

(f) Total Additional Expenses

____________

______

PART IV. SPOUSAL SUPPORT OR APL

With Dependent Children

11. Obligor's Monthly Net

Income (Line 4)

__________________

12. Less Obligee's

Monthly Net Income (Line

(__________________)

13. Difference __________________

14. Less Obligor's Total

Child Support Obligation

(Line 11)

(__________________)

15. Difference __________________

16. Multiply by 30%

1.30

__________________

17. AMOUNT OF MONTHLY SPOUSAL SUPPORT

OR APL

Without Dependent Children

18. Obligor's Monthly Net

Income (Line 4)

__________________

19. Less Obligee's

Monthly Net Income (Line

(__________________)

20. Difference __________________

21. Multiply by 40%

1.40

__________________

22. AMOUNT OF MONTHLY SPOUSAL SUPPORT

OR APL

PROPORTION OF NET INCOME SPENT

ON CHILDREN BY COMBINED INCOME LEVEL

Children

$423-$1,

058

$1,059-$

1,481

$1,482-$

1,905

$1,906-$

2,328

$2,329-$

2,751

$2,752-$3,174

1. $104

plus

24.32%

above

$423

$258,

plus

22.67%

above

$1,059

$354,

plus

22.72%

above

$1,482

$451,

plus

22.32%

above

$1,906

$545,

plus

21.39%

above

$2,329

$636, plus

11.47% above

$2,752

2. $152,

plus

35.44%

above

$423

$377,

plus

32.68%

above

$1,059

$515,

plus

32.77%

above

$1,482

$654,

plus

31.70%

above

$1,906

$788,

plus

31.41%

above

$2,329

$921, plus

16.16% above

$2,752

3. $180,

plus

41.93%

above

$423

$446,

plus

38.34%

above

$1,059

$609,

plus

38.47%

above

$1,482

$772,

plus

36.69%

above

$1,906

$927plus

37.49%

above

$2,329

$1,085 plus

18.62% above

$2,752

4. $199,

plus

46.33%

above

$423

$493,

plus

42.37%

above

$1,059

$673,

plus

42.50%

above

$1,482

$853,

plus

40.54%

above

$1,906

$1,024,

plus

41.42%

above

$2,329

$1,199, plus

20.58% above

$2,752

5. $216,

plus

50.22%

above

$423

$535,

plus

45.92%

above

$1,059

$729,

plus

46.08%

above

$1,482

$924,

plus

43.94%

above

$1,906

$1,110

plus

44.90%

above

$2,329

$1,300 plus

22.30% above

$2,752

6. $231,

plus

53.74%

above

$423

$572,

plus

49.14%

above

$1,059

$780,

plus

49.30%

above

$1,482

$989,

plus

47.02%

above

$1,906

$1,188,

plus

48.04%

above

$2,329

$1,39 plus

23.87% above

$2,752

Children

$3,175-$

3,598

$3,599-$

4,021

$4,022-$

4,656

$4,657-$

5,502

$5,503-$

6,349

1. $684,

plus

7.20%

above

$3,175

$715,

plus

17.74%

above

$3,599

$790,

plus

14.14%

above

$4,022

$879

plus

13.79%

above

$4,657

$996,

plus

13.75%

above

$5,503

2. $989,

plus

11.89%

above

$3,175

$1,040

plus

22.97%

above

$3,599

$1,137,

plus

20.44%

above

$4,022

$1,267,

plus

19.70%

above

$4,657

1,434,

plus

19.74%

above

$5,503

3. $1,164,

plus

10.21%

above

$1,207,

plus

29.49%

above

$1,332,

plus

23.99%

above

$1,485,

plus

22.92%

above

$1,679,

plus

23.11%

above

$3,175 $3,599 $4,022 $4,657 $5,503

4. $1,286,

plus

11.28%

above

$3,175

$1,334,

plus

32.59%

above

$3,599

$1,472,

plus

26.51%

above

$4,022

$1,640,

plus

25.32%

above

$4,657

$1,855,

plus

25.54%

above

$5,503

5. $1,395,

plus

12.22%

above

$3,175

$1,446,

plus

35.33%

above

$3,599

$1,596,

plus

28.74%

above

$4,022

$1,778,

plus

27.45%

above

$4,657

$2,011,

plus

27.68%

above

$5,503

6. $1,492,

plus

13.08%

above

$3,175

$1,548,

plus

37.80%

above

$3,599

$1,708,

plus

30.75%

above

$4,022

$1,903,

plus

29.37%

above

$4,657

$2,151,

plus

29.62%

above

$5,503

Children

$6,350-$

7,195

$7,196-$

8,042

$8,043-$

10,581

$10,582-

$12,697

$12,698-

$15,000

1. $1,113,

plus

13.57%

above

$6,350

$1,227,

plus

7.05%

above

$7,196

$1,287,

plus

15.99%

above

$8,043

$1,693

plus

7.51%

above

$10,582

$1,852,

plus

7.97%

above

$12,698

2. $1,601,

plus

20.37%

above

$6,350

$1,773,

plus

10.65%

above

$7,196

$1,863,

plus

22.93%

above

$8,043

$2,446,

plus

10.95%

above

$10,582

$2,677,

plus

11.60%

above

$12,698

3. $1,874,

plus

24.79%

above

$6,350

$2,084,

plus

13.13%

above

$7,196

$2,195,

plus

26.83%

above

$8,043

$2,877,

plus

13.01%

above

$10,582

$3,152,

plus

14.26%

above

$12,698

4. $2,071,

plus

27.39%

above

$6,350

$2,303,

plus

14.51%

above

$7,196

$2,426,

plus

29.65%

above

$8,043

$3,179,

plus

14.37%

above

$10,582

$3,483,

plus

15.76%

above

$12,698

5. $2,245,

plus

29.69%

above

$6,350

$2,496,

plus

15.73%

above

$7,196

$2,629,

plus

32.14%

above

$8,043

$3,446,

plus

15.58%

above

$10,582

$3,755,

plus

17.08%

above

$12,698

6. $2,402,

plus

31.77%

$2,671,

plus

16.83%

$2,813,

plus

34.39%

$3,687,

plus

16.67%

$4,039,

plus

18.28%

above

$6,350

above

$7,196

above

$8,043

above

$10,582

above

$12,698

FORM 4.10 Affidavit of Consent to Complaint in Support

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

AFFIDAVIT OF CONSENT TO COMPLAINT FOR SUPPORT Pursuant to Pa. R.C.P. 1910.3(4)

I, [name of child], being __________________ years of age, consent to having [name], my parent, act in my place

and stead in the above support action. I further authorize __________________, Esquire, to appear in any proceeding

on my behalf related to the complaint for my support.

IN WITNESS WHEREOF, I set my hand and seal this __________________ day of __________________

20______.

__________________

[name of child]

Sworn to and subscribed

before me this __________________ day

of __________________, 20______.

__________________

Notary Public

I, [name of parent], agree to act for and on behalf of [name of child], as above authorized.

__________________

[name of parent]

FORM 4.11 Medical Child Support Order

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

MEDICAL CHILD SUPPORT ORDER

AND NOW, this __________________, day of 20__________________, it appearing to the Court that:

A. Defendant, __________________ (Social Security

#__________________-__________________-__________________), whose last known mailing address is

__________________ __________________, is employed by __________________ __________________, and has

available to him/her health benefits under the __________________, a group health plan administered by

__________________ [(Group#__________________, Agreement#__________________)] hereinafter ``Plan(s)''; [If

more than one plan, list each with group or agreement numbers and other specific identifying information.]

B. Defendant is father/mother of __________________ (Social security # ______-______-______ and date of

birth);

C. Plaintiff, __________________ (Social Security #

__________________-__________________-__________________), is the custodial parent of said child/children and

resides with them at__________________ ____________.

IT IS ORDERED, ADJUDGED and DECREED as follows:

1. The child/children identified at Paragraph B above shall be ``Alternate Recipients'' within the meaning of Section

609 of the Employee Retirement Income Security Act of 1974 as amended (``ERISA''), which was added by the

Omnibus Reconciliation Act of 1993 (``OBRA `93'').

2. Said Alternate Recipients shall be enrolled in the Plan(s) effective as of __________________ and are to receive

all medical, dental, vision, and other health benefits available to a dependent under any of the employer's group health

plans available to the Participant. They shall receive the coverage that they would be entitled to receive under the

Plan(s) as if they met all of the requirements of a ``dependent'' and thus were dependents under the Plan. Any benefits to

which the Alternative Recipient becomes entitled by reason of this Order which are payable in cash to the Alternate

Recipient or to the Defendant with respect to the Alternate Recipient shall be paid instead to the Alternate Recipient's

custodial parent as set forth at Paragraph C above.

3. Defendant is to make such elections and to consent to such withholding and deductions from pay or otherwise

make required payments as might be necessary in order for the coverage required by this Order to be maintained.

4. This Order applies to the __________________ Plan and any successor plan and applies to each Alternate

Recipient for that period during which, were the Alternate Recipient a dependent, the Alternate Recipient would have

been eligible for or could have elected coverage under the Plan. [List each plan described in Paragraph A.]

5. This Order shall be construed so as not to require the Plan to provide any benefit to an Alternate Recipient which

would not be available to a dependent under the Plan.

6. The parties shall promptly submit this Order to the Plan Administrator(s) for determination of its status as a

Qualified Medical Child Support Order.

7. While this Order is in effect, the parties shall promptly notify the Plan Administrator of any change in:

a.Their addresses from those set forth in this Order;

b.The address of any Alternate Recipient or custodial parent as set forth in this Order;

c.The change in status of any Alternate Recipient such that the Alternate Recipient could no longer

be deemed to be an Alternate Recipient under Section 609 of ERISA; and

d.A change in custodial parent or legal guardian of an Alternate Recipient.

IT IS INTENDED that this Order shall qualify as a Qualified Medical Child Support Order under Section 609 of

ERISA. The Court retains jurisdiction to amend this Order as might be necessary to establish or maintain its status as a

Qualified Medical Child Support Order under Section 609 of ERISA.

BY THE COURT:

__________________

FORM 4.12 Petition for Vocational Evaluation; Rule and Order

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

PETITION FOR VOCATIONAL EVALUATION

AND NOW, Petitioner, __________________, by and through [her/his] attorney, __________________, Esquire,

files this Petition for Vocational Evaluation, and in support thereof, avers as follows:

1. Petitioner, __________________ [``Husband/Wife''], is the [Plaintiff/Defendant] in the above-captioned divorce

action.

2. Respondent, __________________ [``Wife/Husband''], is the [Plaintiff/Defendant] in the above-captioned

divorce action.

3. The parties were married on __________________ [date].

4. The parties separated on __________________ [date].

5. __________________ filed a divorce complaint in the Court of Common Pleas of __________________ County

on __________________, requesting, inter alia, alimony pendente lite, spousal support, and child support.

6. __________________'s earning capacity is at issue in this litigation.

7. __________________ asserts that __________________ is capable of finding employment with a suitable

income to contribute to [his/her] support.

8. __________________ requests that __________________ conduct a vocational evaluation of

__________________.

WHEREFORE, Petitioner, __________________, respectfully requests that this Honorable Court enter an Order

granting a vocational evaluation of __________________.

__________________

Attorney for Petitioner

[Verification]

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

RULE

AND NOW, this __________________ day of __________________, 20______ upon consideration of the Petition

for Vocational Evaluation filed by Petitioner, __________________, a Rule is hereby entered against Respondent,

__________________, to show cause why the relief requested should not be granted.

RULE RETURNABLE, the __________________ day of __________________, 20______.

RULE RETURNABLE, with hearing thereon, the __________________ day of __________________, 20______,

at ______. M., Courtroom ``______'', __________________ County Courthouse, __________________,

__________________, Pennsylvania.

BY THE COURT:

__________________

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

ORDER

AND NOW, this __________________ day of __________________, 20______, upon consideration of the

Petition for Vocational Evaluation filed by Petitioner, __________________, and any Answer thereto filed by

Respondent, __________________, and after a hearing thereon, it is hereby ORDERED and DECREED that said

Petition is GRANTED. Respondent shall submit to a vocational evaluation to be conducted by __________________,

within fourteen (14) days of the date of this Order.

BY THE COURT:

__________________

FORM 4.13 Motion for Special Relief to Vacate Order for College Education Expenses

IN THE COURT OF COMMON PLEAS OF __________________ COUNTY, PENNSYLVANIA

CIVIL ACTION - LAW

PLAINTIFF : No.

v. :

DEFENDANT

: IN SUPPORT

ORDER

AND NOW, this __________________ day of __________________, 20______, upon consideration of

Petitioner's Motion for Special Relief to Vacate Order for College Education Expenses, Respondent's Answer to the

Motion and hearing thereon, it is hereby ORDERED and DECREED that the Court's __________________ Order

requiring Petitioner to finance the parties' minor child(ren)'s college education is VACATED.

BY THE COURT:

__________________

IN THE COURT OF COMMON PLEAS OF __________________ COUNTY, PENNSYLVANIA

CIVIL ACTION-LAW

PLAINTIFF : No.

v. :

DEFENDANT : IN SUPPORT

RULE

AND NOW, this __________________ day of __________________, 20______, upon consideration of

Petitioner's Motion for Special Relief to Vacate Order for College Education Expenses, a RULE is hereby entered upon

Respondent, __________________, to show cause why the relief requested should not be granted.

RULE RETURNABLE, with hearing thereon, the __________________ day of __________________, 20______,

at ____________.m., in Courtroom __________________, __________________ County Courthouse,

__________________, Pennsylvania.

IN THE COURT OF COMMON PLEAS OF __________________ COUNTY, PENNSYLVANIA

CIVIL ACTION - LAW

PLAINTIFF : No.

v. :

DEFENDANT : IN SUPPORT

MOTION FOR SPECIAL RELIEF TO VACATE ORDER

FOR COLLEGE EDUCATION EXPENSES

Petitioner, __________________, by and through his undersigned attorneys, files the Within Motion for Special

Relief to Vacate Order for College Education Expenses, and in support thereof, avers as follows:

1. Petitioner is __________________, who currently resides at __________________.

2. Respondent is __________________, who currently resides at __________________.

3. Petitioner and Respondent are the parents of __________________ minor child(ren), __________________

(born __________________).

4. On __________________, Petitioner was ordered to purchase a zero coupon bond with a face value of

$____________, redeemable in the year ____________ for the express purpose of financing the minor child(ren)'s

college education.

5. Petitioner complied with the Court's Order and purchased a bond under the legend __________________.

6. 23 Pa. C.S.A. § 4327(a) granted courts the authority to order separated, divorced or unmarried parents subject to

a support obligation to provide for their child's educational expenses, including college costs.

7. In 1995, the Pennsylvania Supreme Court ruled that 23 Pa. C.S.A. § 4327(a) was unconstitutional. Curtis v.

Kline, 542 Pa. 249, 666 A.2d 265 (1995).

8. In 1996, the Superior Court of Pennsylvania ruled that existing child support Orders that contained provisions for

college education were rendered ``void'' by the Curtis v. Kline decision. Simmers v. Packer, 451 Pa. Super. 555, 680

A.2d 904 (1996).

9. The Court's __________________ Order that required Petitioner to purchase the zero coupon bond to support the

minor child(ren)'s college education was in effect in __________________ when the Pennsylvania Supreme Court

issued the Curtis v. Kline decision.

10. The Court's __________________ Order was rendered void by the Curtis v. Kline decision in 1995.

WHEREFORE, Petitioner, __________________, respectfully requests this Honorable Court to enter and Order

that the provisions of the __________________ Order for child support requiring Petitioner to purchase a zero coupon

bond for the minor child(ren)'s college education be VACATED and that the funds be released to Petitioner.

Respectfully submitted,

__________________

[Verification]

FORM 5.8 Petition for Appointment of Guardian Ad Litem

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

: IN CUSTODY

PETITION FOR APPOINTMENT OF GUARDIAN AD LITEM

AND NOW, Plaintiff, by and through [his/her] attorney, __________________, Esquire, files a Petition for

Appointment of Guardian Ad Litem, and in support thereof, avers the following:

1. Plaintiff is __________________ [Mother/Father], who currently resides at __________________.

2. Defendant is __________________ [Mother/Father], who currently resides at __________________.

3. The parties hereto are the parents of the following minor [child/children], who currently reside(s) at

__________________.

4. On __________________, 20______, [Mother/Father] filed a Complaint for [Custody/Partial

Custody/Visitation] in the Court of Common Pleas of __________________ County, Pennsylvania.

5. Pa. R.C.P. 1915.11(a) states that ``[t]he court may on its own motion or the motion of a party appoint an attorney

to represent the child in the action. The court may assess the costs upon the parties or any of them or as otherwise

provided by law.''

6. The circumstances of the above-captioned custody action warrant the appointment of a Guardian Ad Litem

because [set forth facts showing that the appointment of a Guardian Ad Litem will be in the best interests and welfare of

the child/children].

WHEREFORE, Plaintiff respectfully requests that this Honorable Court enter an Order of Court appointing

__________________, Esquire, as Guardian Ad Litem of the [child/children] in the abovecaptioned custody action. It is

further requested that this Honorable Court assess the fees and costs of the Guardian Ad Litem upon Defendant.

Respectfully submitted,

__________________

, Esquire

Attorney for Plaintiff

[Verification]

FORM 13.13 Petition for Contempt and to Enforce Property Settlement Agreement

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

PETITION FOR CONTEMPT AND TO ENFORCE PROPERTY SETTLEMENT AGREEMENT

Petitioner, by his/her attorney, brings this Petition for Contempt and to Enforce Property Settlement Agreement

and, in support thereof, avers as follows:

1. Petitioner is __________________, who was the plaintiff in a divorce action between the parties.

2. Respondent is __________________, who was the defendant in that action.

3. On __________________, Petitioner and Respondent entered into a comprehensive Property Settlement

Agreement which, by its terms, determined the equitable distribution of marital property, alimony and support of

Petitioner, and the custody, support and educational expenses of the children. A true and correct copy of the Property

Settlement Agreement is marked as Exhibit ``A,'' attached hereto and made part hereof.

4. On __________________, a final Decree in Divorce was entered by the Court of Common Pleas of

__________________ County, __________________ [name of state], No. ____________, and said Property Settlement

Agreement was incorporated in [but not merged with] the final Decree.

5. Paragraph __________________ of the Property Settlement Agreement provides as follows: [specify]

6. Contrary to the terms of the Property Settlement Agreement, Respondent has/has not [specify].

7. Respondent is in contempt of Court for failing to comply with the terms of Paragraph __________________ of

the Property Settlement Agreement which may be enforced as an Order of the Court under Section 3105(a) of the

Divorce Code, 23 Pa. C.S.A. § 3105(2).

8. Respondent has the ability to comply with the relevant provisions of the Property Settlement Agreement.

9. Respondent should be responsible for Petitioner's counsel fees and costs in connection with the instant Petition.

10. This Court has the authority pursuant to Section 3105(a) and 3502(e) of the Divorce Code of 1980, as amended,

to enter an Order directing Respondent to [specify].

WHEREFORE, Petitioner, __________________, hereby respectfully requests that this Court enter an Order

finding Respondent in Contempt and directing Respondent to [specify].

__________________

Attorney for Petitioner

[Verification]

FORM 13.13A Petition to Enforce Property Settlement Agreement (Oral)

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

PETITION TO ENFORCE PROPERTY SETTLEMENT AGREEMENT (ORAL)

Petitioner, __________________, by and through his/her undersigned counsel, files the within Petition to Enforce

Property Settlement Agreement and, in support thereof, avers as follows:

1. Petitioner is __________________, plaintiff/defendant in the abovecaptioned divorce action.

2. Respondent is __________________, plaintiff/defendant in the abovecaptioned divorce action.

3. On __________________, the parties reached an oral agreement concerning resolution of their economic issues.

4. Both parties have performed certain acts under the terms of the agreement and have acted in reliance on the

agreement.

5. Notwithstanding Respondent's acting under the agreement and his/her receiving certain benefits from the

agreement, Respondent now refuses to comply with the terms of the parties' agreement and refuses to sign a written

agreement embodying the terms to which the parties agreed. A draft of the written agreement is attached hereto as

Exhibit ``A.''

6. Respondent has the ability to comply with the agreement of the parties.

7. This Court has the authority pursuant to § 3105(a) of the Divorce Code, as amended, to enter an Order directing

Respondent to comply with the parties' agreement, the terms of which are embodied in Exhibit ``A'' to the instant

Petition.

WHEREFORE, Petitioner respectfully requests that this Honorable Court enter an Order directing Respondent to

comply with the parties' agreement, the terms of which are embodied in Exhibit ``A'' to the instant Petition.

Respectfully submitted,

__________________

, Esquire

Attorney for Petitioner

[Verification]

FORM 13.15 Petition for Declaratory Judgment to Determine The Validity of Post-Nuptial Agreement

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

PETITION FOR DECLARATORY JUDGMENT TO DETERMINE THE VALIDITY OF POST-NUPTIAL

AGREEMENT

Petitioner by his/her attorney, Petitions this Honorable Court for Declaratory Judgment and avers as follows:

1. Petitioner is __________________ (hereinafter ``Husband''), Defendant in the above-captioned divorce action.

2. Respondent is __________________ (hereinafter ``Wife''), Plaintiff in the above-captioned action.

3. Following their marriage, Husband and Wife entered into a Post-Nuptial Agreement on __________________

[date]. A true and correct copy of the said Post-Nuptial Agreement is marked as Exhibit ``A'' attached hereto and made

a part hereof.

4. The said Post-Nuptial Agreement sets forth various rights of the parties with respect to equitable distribution.

5. An issue has been raised on behalf of [Husband/Wife] with respect to the validity of the aforesaid Post-Nuptial

Agreement, and it would be beneficial to both the parties and the Court to address the validity of said Agreement prior

to the parties proceeding with respect to equitable distribution.

6. This Petition is filed pursuant to Sections 3105, 3501 and 3323 of the Divorce Code.

WHEREFORE, Petitioner respectfully request that this Honorable Court determine the validity of the Post-Nuptial

Agreement.

__________________

Attorney for Petitioner

[Verification]

FORM 13.16 Third Party Petition To Enforce Property Settlement Agreement

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

________________________

ORDER

________________________

AND NOW, this ____________ day of __________________, 20______, after consideration of the Third Party

Petition to Enforce Property Settlement Agreement, any Answer(s) thereto, and after hearing thereon, it is hereby

ORDERED and DECREED as follows:

1. ________________________, is hereby appointed real estate listing agent (``Listing Agent'') for the marital

residence located at __________________.

2. __________________ Esquire and (law firm) are confirmed as the sole escrow agents (``escrow agents'') to

handle the net proceeds from the sale of the marital residence pursuant to the directives of the Agreed Order concerning

the distribution of the net proceeds.

3. Neither Husband nor Wife shall interfere in any way with the marketing and sale of the marital residence by the

listing agent or with the management of the net proceeds from the sale by the escrow agent, and will fully cooperate

with the listing agent and escrow agent.

4. Failure to strictly abide by these terms of this Order and with the terms of the Agreed Order will result in

sanctions.

BY THE COURT:

__________________

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

THIRD PARTY PETITION TO ENFORCE PROPERTY SETTLEMENT AGREEMENT

AND NOW, Petitioner, [Law Firm] submits the foregoing Third Party Petition to Enforce Property Settlement

Agreement, and, in support thereof, asserts as follows:

1. Petitioner is [Law Firm], a third party beneficiary of the Property Settlement Agreement between the

above-named parties.

2. Respondents are Husband and Wife, the parties named above.

3. On __________________ the parties entered into an Agreed Order to resolve all of the economic issues related

to their divorce, and on __________________, this Court entered a Divorce Decree incorporating the terms of the

parties' Agreed Order. A copy of the Decree and the Agreed Order is attached hereto as Exhibit A.

4. Pursuant to the terms of the Agreed Order:a. Wife was to immediately list the marital residence, located at

__________________ for sale with a real estate broker of her choosing, and the sale price was to be set by the real

estate broker.b. __________________, Esquire and [Law Firm] were to be appointed sole escrow agents (``escrow

agents'') for the net proceeds realized from the eventual sale of the marital home.c. The escrow agents were to distribute

the net proceeds realized from the sale of the marital residence by first paying the specific liabilities referenced in the

Agreed Order, by second paying each party's respective counsel fees directly, and finally, by distributing to the parties

any remaining net proceeds in the percentages set forth in the Agreed Order.

5. Upon information and belief, Wife has not listed the marital home for sale as required.

6. [Law Firm] is a third party beneficiary to the Agreed Order between Husband and Wife because the terms of the

Agreed Order specify that it is to receive a portion of the net proceeds from the sale of the marital residence.

WHEREFORE, Petitioner, [Law Firm] respectfully requests that this Honorable Court enter an Order directing the

appointment of a new, neutral real estate listing agent of the Court's choosing to actively market the marital residence,

specifically confirming the continuing position of [Law Firm] as escrow agents to handle the net proceeds from the sale

of the marital residence in accordance with the terms of the Agreed Order.

__________________

, Esquire

Counsel for

[VERIFICATION]

FORM 13.17 Stand-By Qualified Domestic Relations Order

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

________________________

STAND-BY QUALIFIED DOMESTIC RELATIONS ORDER

________________________

WHEREAS, the parties, Husband, hereinafter referred to as the ``Participant,'' and Wife, hereinafter referred to as

the ``Alternate Payee,'' were divorced on __________________ by a Divorce Decree entered by the Court of Common

Pleas of ____________ County, Pennsylvania; and

WHEREAS, the Participant's current and last known mailing address is __________________, Pennsylvania and

his social security number is __________________; and

WHEREAS, the Alternate Payee's current and last known mailing address is __________________, Pennsylvania

and her social security number is __________________; and

WHEREAS, the Participant is employed by __________________ and is a participant in the

__________________ Employees' Profit Sharing Plan, such plan or any successor thereto hereinafter referred to as the

``Plan''; and

WHEREAS, the Plan Administrator is __________________; and

WHEREAS, the Stipulation for Agreed Order provides for the entry of a Stand-by Qualified Domestic Relations

Order pursuant to Section 414(p) of the Internal Revenue Code, as amended, to provide security for the payments to the

Alternate Payee prescribed in the Stipulation for Agreed Order; and

WHEREAS, this assignment of benefits does not require the Plan to provide any type or form of benefit, or any

option not otherwise provided under the Plan as determined under Section 414(p) of the Internal Revenue Code; this

assignment does not require the Plan to provide increased benefits (determined on the basis of actuarial value); and this

assignment does not require the Plan to provide benefits to the Alternate Payee which are required to be paid to another

alternate payee under another order previously determined to be a qualified domestic relations order.

It is therefore, ORDERED, ADJUDGED, and DECREED as follows:

1. Amount of Benefits.

The Alternate Payee is awarded from the Participant's accrued benefit under the Plan $ ____________ a month

minus the amount of alimony the Participant pays in accordance with the Stipulation for Agreed Order each month. This

award shall continue in effect until Alternate Payee's death, and this Order shall be of no force and effect thereafter

except as to alimony payments required under the Stipulation for Agreed Order that remain unsatisfied.

2. Time and Manner of Payment.

If the Participant is required to make an alimony payment for a month under the Stipulation for Agreed Order and

any portion remains unpaid 15 days after the end of the month, the Alternate Payee may notify the Plan Administrator

of the Payee's failure to satisfy the alimony obligation. Upon receipt of written notification from the Alternate Payee,

the Plan Administrator shall pay promptly to the Alternate Payee from the Participant's benefit under the Plan an

amount equal to such unpaid portion.

3. Liability for Income Taxes.

Alternate Payee shall be solely responsible for, and bear the burden of, all federal, state and local income taxes,

penalties, fines, interest and/or other taxes of any nature, if any, due from and/or payable by her with respect to all

amounts she receives under this Stand-by QDRO, and she shall exonerate, indemnify and hold harmless the Participant

from any resulting liabilities, including, but not limited to, any federal, state and local income taxes, penalties, fines,

interest and/or taxes of any nature.

On a quarterly basis (April 15, June 15, September 15 in each year and January 15 in the next succeeding year), the

Plan shall disburse to the Alternate Payee from Participant's accrued benefit a sum equal to the amount of Federal and

Pennsylvania income tax (if any is imposed) payable by Wife on amounts received under this Stand-by QDRO since the

last quarterly disbursement. In determining the Federal and Pennsylvania income taxes of the Alternate Payee for a

quarterly disbursement, the rate of tax shall be calculated as if (i) the distribution payments under Paragraph 1 were the

Alternate Payee's sole income and (ii) that she claimed __________________ exemptions and (iii) distributions

payments since the last quarterly disbursement would continue at the same rate for the remainder of the year.

4. Alternate Payee as Surviving Spouse.

The Alternate Payee shall be treated under the Plan as the surviving spouse of the Participant only to the extent of

the Participant's maximum remaining obligation for non-taxable alimony payments under the Stipulation for Agreed

Order. The Participant shall make no election inconsistent with this Order concerning benefits provided to the Alternate

Payee under this Order and the Plan Administrator shall not recognize any election or beneficiary designation by the

Participant inconsistent herewith. The death benefit payable to the Alternate Payee as the Participant's surviving spouse

upon Participant's death, if any, shall be payable only to the extent of the Alternate Payee's entitlement to benefits as

provided in Section 1 herein. The Plan Administrator shall not take any action which will cause any amount due to the

Alternate Payee or her beneficiary to be paid to any other person or entity under any circumstances.

5. No Additional Benefits to Alternate Payee.

The Alternate Payee is not entitled to any benefit not otherwise provided under the Plan or this Order. The

Alternate Payee is only entitled to the specific benefits under the Plan as provided for in this Order.

6. Change of Address.

The parties shall promptly notify the Plan Administrator of any change in their addresses from those set forth in this

Order.

WHEREFORE, it is intended that this Order shall qualify as a Qualified Domestic Relations Order under the

Employee Retirement Income Security Act of 1974 and Section 414(p) of the Internal Revenue Code, as amended. The

Court retains jurisdiction to amend this Order as might be necessary to establish or to maintain its status as a Qualified

Domestic Relations Order.

So stipulated:

__________________ __________________

Participant Alternate Payee

__________________ __________________

Date Date

ORDER

AND NOW, this ____________ day of ____________, 20______, this Stipulation is hereby approved as an

ORDER of this Court.

BY THE COURT:

__________________

FORM 14.3 Order

AND NOW, this ____________ day of __________________, 20______, it is hereby ORDERED and DECREED,

that the attached [Date] Amendment to Agreement is hereby approved and made an Order of the Court.

BY THE COURT:

__________________

FORM 15.2 Complaint for Specific Performance, Support and Other Relief

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

CIVIL ACTION-EQUITY

MARY

SMIT

: N

321

Front

Street

Philadelphia,

19103,

Plaintiff :

v. :

ROBE

RT F.

DOE

123

Brown

Street

Philadelphia,

19103,

Defendant:

COMPLAINT FOR SPECIFIC PERFORMANCE, SUPPORT AND OTHER RELIEF

AND NOW comes the Plaintiff, MARY SMITH, by her attorney, John Jones, and respectfully represents:

1. Both parties are unmarried adults and residents of the Commonwealth of Pennsylvania.

2. On or about December 20, 1967, the Plaintiff and ROBERT F. DOE, Defendant, began living together at 123

Brown Street, Philadelphia, Pennsylvania 19103.

3. On or about December 20, 1967, the parties intended to and did enter into a written agreement to live together at

the aforementioned residence; to care for each other; and to provide a comfortable home and living for each other for

the remainder of their lives. A true and correct copy of said agreement is attached as Exhibit ``A.'' [Note: No agreement

attached]

4. Both parties understood that the terms ``to provide a comfortable home and living for each other'' meant and

were intended to include, but were not limited to, the provision of food, lodging, clothing, medical care, laundry

services and a congenial environment. Each party was expected to contribute his or her skills, financial resources and

services to the best of his or her ability.

5. Plaintiff did at all times fulfill her promise by performing services for the Defendant, including but not limited

to, shopping and preparing the couple's meals, providing the couple with laundered clothes and a clean home, nursing

the Defendant when he was ill and contributing any money she received from whatever source to the couple's joint bank

account.

6. On or about February 5, 1989, the Defendant constructively abandoned and deserted Plaintiff, and forced

Plaintiff to leave the aforementioned premises and has not since that time provided Plaintiff with a home or any form of

support.

7. Defendant's actions constitute a breach of the contract entered into between the parties.

8. During the twenty-two years in which the parties lived together, Plaintiff assisted Defendant in the advancement

of his career, and in reliance upon the parties' agreement to live together and to provide a comfortable home for each

other, declined to pursue her own career, so that she is now lacking marketable skills and is substantially unemployable.

9. The parties have substantial property both real and personal, tangible and intangible, which was acquired during

the time they lived together, including household furnishings, appliances and art work.

10. Plaintiff has suffered substantial injury and has no adequate remedy at law.

WHEREFORE, the Plaintiff prays that this Court order the following relief:

A. Specific enforcement of the parties' agreement;

B. Order the Defendant to pay a reasonable amount to support Plaintiff in the manner that she would have been

supported if the parties had continued to live together in accordance with their agreement;

C. Determine the ownership of all property, real and personal, tangible and intangible, owned individually or jointly

by the parties, and order a partition or sale of all jointly owned property and a division of the proceeds;

D. Instruct the Defendant to pay Plaintiff's reasonable counsel fees, and the costs of these proceedings;

E. Award to Plaintiff such other and further relief as the nature of her cause may require.

__________________

JOHN JONES

[Address and Telephone]

Attorney for Plaintiff

VERIFICATION

Mary Smith verifies that the statements made in the attached Complaint are true and correct. She understands that

false statements herein are made subject to 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities.

__________________

Mary Smith

FORM 15.3 Complaint for Declaration of Trust, Support and Other Relief

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

CIVIL ACTION-EQUITY

MARY

SMIT

: N

321

Front

Street

Philadelphia,

19103,

Plaintiff :

v. :

ROBE

RT F.

DOE

123

Brown

Street

Philadelphia,

19103,

Defendant:

COMPLAINT FOR DECLARATION OF TRUST, SUPPORT AND OTHER RELIEF

AND NOW comes the Plaintiff, MARY SMITH, by her attorney, John Jones, and respectfully represents:

1. Both parties are unmarried adults and residents of the Commonwealth of Pennsylvania.

2. On or about December 20, 1967, the parties began living together at 123 Brown Street, Philadelphia,

Pennsylvania 19103, upon Defendant's representations and promises that if Plaintiff lived with him and kept house for

him and otherwise contributed her skills and time to the making of a comfortable home, Defendant would provide

financially for Plaintiff's needs for the rest of her life.

3. Plaintiff agreed to do so, upon Defendant's representations and promises.

4. Plaintiff, at all times pertinent hereto, was employed parttime as a nurse and continued to work as such during

the time she was living with Defendant.

5. In reliance on Defendant's representations and promises that he would provide financially for her needs, Plaintiff

regularly turned over to Defendant all of her earnings.

6. In addition, Defendant induced Plaintiff to give to him certain savings, securities and other assets which she

owned prior to the commencement of her relationship with the Defendant, upon the representation that he would

provide financially for her needs; that said savings, securities and other assets are valued at more than $10,000.

7. Throughout the time that the parties lived together, they were in a confidential relationship in which Plaintiff

reasonably believed that Defendant would not act in a manner inconsistent with her welfare, and Plaintiff trusted

Defendant; that Defendant abused such confidential relationship and took advantage of Plaintiff's trust to obtain

property and earnings in his own name for his own benefit.

8. Defendant knew that he had no intention of providing financially for Plaintiff's needs but, instead, he deliberately

misrepresented his intention to Plaintiff for the purpose of acquiring her savings, securities and other assets.

9. On or about February 5, 1989, the Defendant constructively abandoned and deserted Plaintiff, and forced

Plaintiff to leave the aforementioned premises and has not since that time provided Plaintiff with a home or any form of

support.

10. Although Plaintiff has demanded the return of her earnings, savings, securities and other assets, Defendant has

refused to return any of them.

11. As a result of Defendant's willful and fraudulent misrepresentations, and his breach of the parties' confidential

relationship, Plaintiff has suffered substantial damages and has no adequate remedy at law.

WHEREFORE, the Plaintiff prays that this Court:

A. Determine that all earnings, savings, securities and other assets acquired by the Defendant from the Plaintiff are

held in a constructive trust for the benefit of Plaintiff;

B. Order the Defendant to return to the Plaintiff all earnings, savings, securities, and other assets that are held in

trust;

C. Order the Defendant to pay a reasonable amount to support Plaintiff in the manner that she would have been

supported by the Defendant had the parties continued to live together in accordance with their agreement;

D. Determine ownership of all real or personal, tangible and intangible property owned by the parties, either

individually or jointly, and order a partition or sale in lieu of partition of all jointly owned property and a division of the

proceeds;

E. Order Defendant to pay Plaintiff's reasonable counsel fees, and the costs of these proceedings;

F. Award to Plaintiff such other and further relief as the nature of her cause may require.

__________________

JOHN JONES

[Address and Telephone]

Attorney for Plaintiff

VERIFICATION

Mary Smith verifies that the statements made in the attached Complaint are true and correct. She understands that

false statements herein are made subject to 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities.

__________________

Mary Smith

FORM 15.4 Complaint for Declaration of Resulting Trust, Support and Other Relief

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

CIVIL ACTION-EQUITY

MARY

SMIT

: N

321

Front

Street

Philadelphia,

19103,

Plaintiff :

v. :

ROBE

RT F.

DOE

123

Brown

Street

Philadelphia,

19103,

Defendant:

COMPLAINT FOR DECLARATION OF RESULTING TRUST, SUPPORT AND OTHER RELIEF

AND NOW comes the Plaintiff, MARY SMITH, by her attorney, John Jones, and respectfully represents:

1. Both parties are unmarried adults and residents of the Commonwealth of Pennsylvania.

2. On or about December 20, 1967, the Plaintiff and ROBERT F. DOE, Defendant, began living together at 123

Brown Street, Philadelphia, Pennsylvania 19103.

7. On or about January 1, 1978, the Plaintiff gave Defendant a sum of money with which the parties purchased an

automobile for Plaintiff's use.

8. The automobile was titled in Defendant's name solely for insurance purposes.

9. On or about February 5, 1989, the Defendant did force the Plaintiff to leave the aforementioned premises.

10. The Defendant took possession of the automobile and changed the lock on the automobile.

11. Plaintiff did not intend to give the automobile to Defendant as a gift.

WHEREFORE, Plaintiff prays that this Court grant the following relief:

A. Issue an Order to the effect that the automobile, acquired with Plaintiff's assets, but titled in Defendant's name, is

held by the Defendant as part of a resulting trust for the benefit of the Plaintiff;

B. Order the Defendant to transfer title of the automobile to the Plaintiff and deliver possession of the automobile to

the Plaintiff;

C. Order the Defendant to pay Plaintiff's reasonable counsel fees, and the costs of these proceedings;

D. Award to the Plaintiff such other and further relief as the nature of her cause may require.

__________________

JOHN JONES

[Address and Telephone]

Attorney for Plaintiff

VERIFICATION

Mary Smith verifies that the statements made in the attached Complaint are true and correct. She understands that

false statements herein are made subject to 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities.

__________________

Mary Smith

FORM 15.5 Complaint for Support and Division of Property

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

CIVIL ACTION-EQUITY

MARY

SMIT

: N

321

Front

Street

Philadelphia,

19103,

Plaintiff :

v. :

ROBE

RT F.

DOE

123

Brown

Street

Philadelphia,

19103,

Defendant:

COMPLAINT FOR SUPPORT AND DIVISION OF PROPERTY

AND NOW comes the Plaintiff, MARY SMITH, by her attorney, John Jones, and respectfully represents:

1. Both parties are unmarried adults and residents of the Commonwealth of Pennsylvania.

2. On or about December 20, 1967, the Plaintiff and ROBERT F. DOE, Defendant, began living together at 123

Brown Street, Philadelphia, Pennsylvania 19103.

3. On or about December 20, 1967, the parties entered into an equal partnership for the purpose of pursuing their

common living arrangement.

4. In furtherance of this partnership, the parties purchased real property and titled it in both of their names;

borrowed money as co-signers; conducted business as equal partners; opened a joint bank account and pooled their

respective earnings; and used their pooled earnings to purchase personal property and to make improvements on their

real property.

5. On or about February 5, 1989, the Defendant did constructively abandon and desert Plaintiff, and forced Plaintiff

to leave the parties' residence.

6. The parties have substantial personal property, including stocks, bonds and other securities, and bank accounts,

some of which are titled in the joint names of the parties and others of which are titled in the name of the Plaintiff or the

Defendant separately.

WHEREFORE, Plaintiff prays that this Court issue the following relief:

A. Determine the ownership of all real property of the parties, held either individually or jointly, and all tangible

and intangible personal property of the parties, held either individually or jointly, and order a partition or sale in lieu of

partition of all jointly owned property and division of the proceeds;

B. Order Defendant to pay Plaintiff's reasonable counsel fees, and the costs of these proceedings;

C. Award to Plaintiff such other and further relief as the nature of her cause may require.

__________________

JOHN JONES

[Address and Telephone]

Attorney for Plaintiff

VERIFICATION

Mary Smith verifies that the statements made in the attached Complaint are true and correct. She understands that

false statements herein are made subject to 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities.

__________________

Mary Smith

FORM 15.6 Preliminary Objections-Motion to Dismiss for Failure to State a Cause of Action

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

CIVIL ACTION-EQUITY

MARY

SMIT

: N

321

Front

Street

Philadelphia,

19103,

Plaintiff :

v. :

ROBE

RT F.

DOE

123

Brown

Street

Philadelphia,

19103,

Defendant:

PRELIMINARY OBJECTIONS IN THE NATURE OF A DEMURRER

AND NOW, this ____________ day of __________________, 20______, comes ROBERT F. DOE, through his

attorney Andrew Brown, to file these Preliminary Objections in the nature of a Motion to Dismiss for the reasons

hereinafter set forth:

1. The Plaintiff's Complaint fails to state facts constituting a cause of action against this Defendant.

2. The consideration provided by Plaintiff for the contract alleged in the Complaint is based solely upon sexual

services.

3. The contract lacked consideration and is, therefore, void and unenforceable.

WHEREFORE, the Defendant requests that this Court dismiss the Plaintiff's Complaint and enter judgment in favor

of the Defendant.

__________________

ANDREW BROWN

[Address and Telephone]

Attorney for Defendant

VERIFICATION

Robert F. Doe verifies that the statements made in the attached Complaint are true and correct. He understands that

false statements herein are made subject to 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities.

__________________

Robert F. Doe

FORM 15.7 Answer to Complaint for Specific Performance, Support and Other Relief, and New Matter

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

CIVIL ACTION-EQUITY

MARY

SMIT

: N

321

Front

Street

Philadelphia,

19103,

Plaintiff :

v. :

ROBE

RT F.

DOE

123

Brown

Street

Philadelphia,

19103,

Defendant:

DEFENDANT'S ANSWER TO COMPLAINT FOR SPECIFIC PERFORMANCE, SUPPORT AND OTHER

RELIEF, AND NEW MATTER

AND NOW comes the Defendant, ROBERT F. DOE, by his attorney, Andrew Brown, and respectfully responds as

follows:

1. Admitted.

2. Admitted.

3. Admitted in part; denied in part. It is admitted that the parties entered into a written agreement on December 20,

1967 to live together, to care for each other and to provide a comfortable income for one another; however, it is denied

that the parties intended to be bound by the agreement for the rest of their lives. To the contrary, the agreement was

intended to last only so long as both parties were satisfied with the cohabitation.

4. Denied. It is denied that he understood the term ``to provide a comfortable home and living for each other'' to

include the provision of food, lodging, clothing, medical care, laundry services and a congenial environment. To the

contrary, he understood the promise to provide ``a comfortable living and home to each other'' referred to the emotional

and psychological aspects of the union, not to the daily responsibilities of the parties. It is denied that he expected the

Plaintiff to contribute all of her energy and skills to his benefit for the rest of their lives. He further avers that he is

without knowledge or sufficient information to form a belief as to the truth of the assertion that the Plaintiff expected

both parties to contribute skills, financial resources, and services to the best of their ability for the rest of their lives, and

strict proof thereof is demanded, if relevant.

5. Denied. It is denied that Plaintiff had any contractual duty to shop, prepare meals, launder the clothes, clean the

home, nurse the Defendant when he was ill or to contribute money to the couple's joint bank account. Defendant avers

that he often helped Plaintiff to perform these tasks and that both parties acted voluntarily rather than out of a

contractual obligation.

6. Admitted in part; denied in part. Defendant denies that he constructively abandoned and deserted Plaintiff and

forced her to leave the home. Defendant avers that both parties reached a mutual agreement, due to their inability to live

peaceably together, that their period of cohabitation would end. Defendant denies that he forced Plaintiff to move. He

avers Plaintiff acquiesced to his request that she leave the premises. Defendant admits that he has not provided the

Plaintiff with any home or form of support since the alleged date.

7. Denied as a conclusion to which no response is required.

8. Admitted in part; denied in part. Defendant denies that Plaintiff in any way assisted him in the advancement of

his career. He admits that Plaintiff failed to pursue her own career. Defendant denies that Plaintiff failed to pursue her

career in reliance upon the parties' agreement to live together. Defendant further denies that Plaintiff is without

marketable skills. He asserts that Plaintiff has a college degree and is capable of supporting herself.

9. Denied as stated. Defendant denies that both parties have a possessory right to the furnishings, appliances and

artwork in the home since the home was fully furnished prior to the Plaintiff's decision to cohabitate with the Defendant.

Defendant argues that only the property acquired during the relationship with jointly held funds can be subject to

partition or to distribution.

10. Denied as a conclusion to which no response is required.

WHEREFORE, Defendant requests that this Court deny the Plaintiff's request for specific performance, support,

partition and counsel fees.

NEW MATTER

In further response to Plaintiff's Complaint, Defendant avers the following new matter:

11. Plaintiff has provided insufficient consideration to justify lifetime support or partition of Defendant's

individually owned property.

12. The alleged contract claimed by Plaintiff is unenforceable and void because it lacks sufficient consideration.

WHEREFORE, the Defendant requests that Plaintiff's Complaint be dismissed and judgment be entered in favor of

Defendant.

__________________

ANDREW BROWN

[Address and Telephone]

Attorney for Defendant

VERIFICATION

Robert F. Doe verifies that the statements made in the attached Complaint are true and correct. He understands that

false statements herein are made subject to 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities.

__________________

Robert F. Doe

FORM 16.3 Petition to Set Aside Antenuptial Agreement

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

PETITION TO SET ASIDE ANTENUPTIAL AGREEMENT

Petitioner, by his/her attorney, hereby requests this Honorable Court to set aside the Antenuptial Agreement entered

into by the parties on (date). In support thereof, Petitioner avers as follows:

1. This is an action in divorce instituted by Plaintiff [Husband/ Wife] on (date).

2. The parties were married on (date) and separated on or about (date).

3. Prior to their marriage on (date), the parties signed an Antenuptial Agreement. A true and correct copy of said

Agreement is marked Exhibit ``A,'' attached hereto and made a part hereof.

4. Petitioner avers that said Antenuptial Agreement is null and void, invalid and unenforceable for the following

reasons:

a. Said Agreement is not supported by valid consideration.

b. At the time the Petitioner signed the Antenuptial Agreement, he/she was [unrepresented by counsel, coerced into

signing the Agreement, fraudulently induced to enter into the Agreement, under duress, not advised that he/she could or

should have the Agreement reviewed by an attorney, never given the opportunity to have the Agreement reviewed by an

attorney, not advised of his/her rights, not advised of the rights that he/she was waiving].

c. The Agreement does not contain full and complete financial disclosures by the parties, Petitioner was unaware of

Respondent's financial circumstances.

d. Petitioner was advised by Respondent that the Agreement was only entered into to please Respondent's family,

and that Petitioner should not be concerned about the Agreement.

Page 120

5. the Antenuptial Agreement between the parties is null and void and should be set aside.

WHEREFORE, Petitioner prays this Honorable Court to enter an Order setting aside the antenuptial Agreement

signed by the parties and to allow Petitioner to proceed with his/her claims for economic relief under the Divorce Code.

__________________

Attorney for Petitioner

[Verification]

FORM 16.4 Petition for Declaratory Judgment of Validity of Antenuptial Agreement

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

PETITION FOR DECLARATORY JUDGMENT OF VALIDITY OF AGREEMENT

Petitioner, by and through his/her attorney, files this request for declaratory judgment and avers as follows:

1. This is an action in divorce instituted by Plaintiff [Husband/ Wife] on [date].

2. The parties were married on [date] and separated on or about [date].

3. Prior to their marriage on [date], the parties signed an Antenuptial Agreement. A true and correct copy of said

Agreement is marked Exhibit ``A,'' attached hereto and made a part hereof.

4. This Petition is filed pursuant to Sections 3105, 3323, and 3501 of the Divorce Code of Pennsylvania.

5. On (date), the parties entered into an Antenuptial Agreement setting forth the rights of the parties with respect to

equitable distribution, alimony pendente lite, spousal support, counsel fees and costs.

7. When Plaintiff/Defendant filed the above-captioned divorce action/counterclaim seeking all statutory relif

available, it was apparent that Plaintiff/Defendant was not intending to abide by the terms of the Agreement.

8. The existence of the Antenuptial Agreement has now been specifically averred and it is requested that this

Honorable Court specifically enforce the terms of that Agreement.

9. It is necessary that the validity of this Antenuptial Agreement be established before the Agreement can be

specifically enforced and/or utilized to defend the economic claims made.

10. It is requested that this Honorable Court, after a hearing, issue a Declaratory Judgment establishing the validity

of this Antenuptial Agreement pursuant to 42 Pa. C.S.A. §§ 7531 et seq.

11. It will be a waste of judicial time and economy and a potential waste of each party's resources to litigate the

economic issues raised in the Complaint/Counterclaim before determining the validity of the Antenuptial Agreement.

12. It is in the best interests of the judiciary and the parties for this Honorable Court to issue a Declaratory

Judgment as to the validity of the Antenuptial Agreement before extensive discovery is undertaken, Master's hearings

conducted and extensive legal efforts expended when a Declaratory Judgment would assist the parties in focusing on

whether the Antenuptial Agreement will control certain outstanding issues or whether it will be unenforceable as to

some or all outstanding issues.

WHEREFORE, after a hearing is held, it is respectfully requested that this Honorable Court enter an Order

(a)that the Antenuptial Agreement attached hereto as Exhibit ``A'' is valid and binding upon Plaintiff

and Defendant;

(b)that the terms of the Antenuptial Agreement be specifically enforced.

Respectfully Submitted,

__________________

Attorney for Petitioner

[Verification]

FORM 18.3 Acknowledgment of Paternity and Waiver of Trial

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT :

ACKNOWLEDGMENT OF PATERNITY AND WAIVER OF TRIAL

I, [Defendant], do hereby acknowledge that I am the father of the child, [Name of Child], born on [Date] in [City,

County, State]. This child was born to [Name of Mother] of [City, State].

I have been advised of and do hereby waive my rights to (1) a trial on the issue of paternity which must be proven

by a preponderance of the evidence and (2) an attorney to represent me on the issue of paternity both at the trial thereon

and in this action for support.

__________________

DOMESTIC RELATIONS

OFFICER

__________________

DEFENDANT

__________________

, Esquire

Attorney for Defendant

[Verification]

FORM 18.4 Notice of Right to Trial on Issue of Paternity

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT : IN PATERNITY

NOTICE OF RIGHT TO TRIAL ON ISSUE OF PATERNITY

The defendant has not acknowledged paternity of the child [Child's Name], born on [Date], in [City, State] to

[Mother's Name]. You are hereby advised of your rights to (1) a trial on the issue of paternity and (2) an attorney to

represent you on the issue of paternity and in any support proceedings. If the Court determines that you are indigent,

and you request it, an attorney will be provided to you on the issue of paternity only.

The trial shall be without jury unless either you or the other party demand a trial by jury in writing within ten days

from the date of this notice.

__________________

DOMESTIC RELATIONS

OFFICER

Date: __________________

I acknowledge receipt of a copy of this notice this ____________ day of __________________, 20______.

__________________

[Plaintiff/Defendant]

FORM 18.5 Order to Appear for Genetic Testing

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT :

ORDER TO APPEAR FOR GENETIC TESTING

The defendant has not acknowledged paternity of the child __________________, born on __________________

[Date], in __________________ [City, State] to __________________ [Mother].

The parties and the child are ordered to appear for genetic testing on ____________, 20______, at

__________________ o'clock __________________ m. at __________________ and to stay until excused.

If the defendant fails to appear for genetic testing as ordered, the court will enter an order finding the defendant is

the father of the child. If the plaintiff fails to appear or fails to make the child available for testing as ordered, the court

may enter an order dismissing the paternity action without prejudice.

BY THE COURT:

__________________

FORM 18.6 Stipulation of Paternity

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT :

STIPULATION OF PATERNITY

The parties hereby agree to submit to genetic tests for the purpose of resolving finally the issue of paternity in this

case. The parties further agree that if the test results indicate a probability of paternity 99% or higher, the defendant

shall be stipulated to be the biological father of the minor child and the case shall be set promptly for a child support

conference. If the test results indicate an exclusion, the action shall be dismissed.

I have been advised of and do hereby waive my rights to (1) a trial on the issue of paternity and (2) an attorney to

represent me on the issue of paternity.

__________________

Plaintiff

__________________

Defendant

FORM 18.7 Order re Stipulation

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT :

ORDER RE STIPULATION

AND NOW, this ____________ day of __________________, 20______, in accordance with the stipulation of the

parties, it is hereby ordered that

[] 1) Defendant is the biological father of the child [NAME OF CHILD] born on [CHILD'S DATE

OF BIRTH] to [CHILD'S MOTHER'S NAME] and the matter shall be set promptly for a support

conference.

[] 2) Defendant is not the biological father of the child [NAME OF CHILD] born on [CHILD'S

DATE OF BIRTH] to [CHILD'S MOTHER'S NAME] and this paternity action is dismissed.

BY THE COURT,

__________________

FORM 21.2 Petition for Protection from Abuse

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. : PROTECTION FROM ABUSE

DEFENDANT :

PETITION FOR PROTECTION FROM ABUSE

1. Plaintiff's name is: __________________

2. 1 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 checked ``another person,'' please answer all questions

referring to that person as the ``Plaintiff, and provide your address here, unless confidential: 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)

3. Name(s) of ALL person(s), including Plaintiff and minor children, who seek protection from abuse:

__________________

4. [ ]Plaintiff's address is confidentialor[ ] Plaintiff's address is:

5.Defendant is believed to live at the following address: __________________

__________________

Defendant's Social Security Number (if known) is: __________________

Defendant's date of birth is: ____________

Defendant's place of employment is: __________________

[ ] Check here if you have reason to believe that Defendant is a licensed firearms dealer or is employed

in a profession that requires Defendant to handle firearms or to carry a firearm as a condition of

employment.

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

6.Indicate the relationship between Plaintiff and Defendant.

[ ]Spouse [ ]Current or

former sexual/

intimate partner

[ ]Other relationship

by blood or

marriage:

_____________

_____

[ ]Ex-spouse [ ]Parent/Child [ ]_____________

_____

[ ]Persons who

live or have

lived like

spouses

[ ]Parents of the

same children

[ ]Brother/Sister

7. 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: __________________

8. Has the Defendant been involved in any criminal court action? __________________

If you answered Yes, is the Defendant currently on probation? __________________

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

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

unless confidential)

____________

______

_______

____

__________________

____________

______

_______

____

__________________

____________

______

_______

____

__________________

____________

______

_______

____

__________________

10. 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(s)

Person(

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

____________

______

__________

________

__________________

____________

______

__________

________

__________________

____________

______

__________

________

__________________

____________

______

__________

________

__________________

____________

______

__________

________

__________________

____________

______

__________

________

__________________

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

Name Age(s) Plaintiff's relationship to

children

____________ _______ __________________

______ _______

____

____________

______

_______

____

__________________

____________

______

_______

____

__________________

____________

______

_______

____

__________________

____________

______

_______

____

__________________

____________

______

_______

____

__________________

12. 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):

__________________

13. If the 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): __________________

__________________

14. (a) Has Defendant used or threatened to use any firearms or other weapons against Plaintiff or the minor

child/ren? If so, please describe: (b) To the best of your knowledge or belief, does Defendant own or possess any

firearm, other weapon, ammunition, or any firearm license? (c) If the answer to (b) above is ``yes,'' list any firearm,

other weapon, or ammunition owned by or in the possession of Defendant on Attachment A, which is incorporated by

reference into this petition.

15. Identify the police department or law enforcement agency in the area in which Plaintiff lives that should be

provided with a copy of the protection order: __________________

__________________

16. There is an immediate and present danger of further abuse from the 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 the 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 REASONS SET FORTH ABOVE, I REQUEST THAT THE COURT ENTER A TEMPORARY ORDER,

and AFTER HEARING, A FINAL ORDER THAT WOULD DO THE FOLLOWING (CHECK ALL FORMS OF

RELIEF REQUESTED):

[ ] A. Restrain Defendant from abusing, threatening, harassing, or stalking Plaintiff and/or minor child/ren in any

place where Plaintiff may be found.

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

temporary or permanent residence of the Plaintiff.

[ ] C. Require Defendant to provide Plaintiff and/or 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 children:__________________

__________________

[ ] E. Prohibit Defendant from having any contact with Plaintiff and/or 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.

[ ] G. Order Defendant to temporarily relinquish any firearm, other weapon, ammunition, and any firearm license

to the sheriff of this county and prohibit Defendant from transferring, acquiring, or possessing any firearm, other

weapon, ammunition, or any firearm license 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 the court deems appropriate.

[ ] N. Order the police or other law enforcement agency to serve the Defendant with a copy of this Petition, any

Order issued, and the Order for Hearing. The petitioner 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. § 4904, relating to unsworn falsification to authorities.

__________________

Signature

__________________

Date

(Caption)

PETITIONER'S ATTACHMENT A FIREARMS, OTHER WEAPONS, AND AMMUNITION INVENTORY

I, __________________, Plaintiff in this Protection From Abuse Action, hereby request the court order Defendant

to relinquish the following firearms, other weapons, ammunition, and firearm licenses to the sheriff:

10.

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

I believe the above items are located at: __________________. (List all relevant addresses where they may be

found)

__________________ Name

__________________ Date

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

FORM 21.3 Verification of Inability to Pay Costs

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. : PROTECTION FROM ABUSE

DEFENDANT :

VERIFICATION OF INABILITY TO PAY COSTS

I verify that I am the Plaintiff in the Petition for protection under the Protection from Abuse Act. I do not have

money available today to pay the costs of filing and service in this lawsuit. I understand that at the hearing on this

Petition, the Court will decide whether I have funds available and that the Court may assign the costs of this litigation to

the Defendant or to me or may waive the costs.

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.

__________________

Plaintiff

FORM 21.4 Temporary Order

[Complete applicable provisions of form; manually cross out inapplicable provisions in ink, but do not renumber

paragraphs, because of uniform paragraph-numbering requirements of statewide registry of protection orders.]

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. : PROTECTION FROM ABUSE

DEFENDANT :

TEMPORARY PROTECTION FROM ABUSE ORDER

Defendant's Name: __________________

Defendant's Date of Birth: ____________

Defendant's Social Security Number: ____________

Names of All Protected Persons, including Plaintiff and minor child/ren:__________________

__________________

AND NOW, this ____________ day of __________________, 20______ upon consideration of the attached

Petition for Protection from Abuse, the court hereby enters the following Temporary Order:

[ ] 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 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 protected person under this order,

either directly or indirectly, at any location, 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 protected person under this order, either directly or indirectly, at any

location, by telephone or by any other means, including through third persons.

[ ] 5. Pending the outcome of the final hearing in this matter, Plaintiff is awarded temporary custody of the

following minor child/ren: __________________

__________________ Until the final hearing, all contact between Defendant and the child/ren shall be limited to the

following:__________________

__________________

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

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

Check all that apply: [ ] Defendant shall relinquish to the sheriff all firearms and firearms licenses owned or possessed

by Defendant. [ ] Defendant is directed to relinquish to the sheriff any firearm, other weapon, or ammunition listed in

Petitioner's Attachment A, and any firearms license Defendant may possess.

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,

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 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:

__________________

[ ] 8. A certified copy of this Order shall be provided to the police department where Plaintiff resides and any other

agency specified hereafter: [insert name of agency]

[ ] 9. THIS ORDER SUPERSEDES[ ] ANY PRIOR PFA ORDER AND [ ] ANY PRIOR ORDER RELATING

TO CHILD CUSTODY.

10. THIS ORDER APPLIES IMMEDIATELY TO DEFENDANT AND SHALL REMAIN IN EFFECT UNTIL

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 $1,000.00 and/or up to six months in jail. 23 Pa. C.S. § 6114. Consent of the 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. § 6113. If Defendant is required to relinquish any

firearms, other weapons, or ammunition or any firearms 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. 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 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.

BY THE COURT:

__________________

Judge

__________________

Date

FORM 21.5 Notice of Hearing and Order

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. : PROTECTION FROM ABUSE

DEFENDANT :

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 and lose other important rights. 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______,

____________.m., in Courtroom __________________ at __________________ Courthouse, __________________,

Pennsylvania.

You MUST obey the Order that is attached until it is modified or terminated by the court after notice and hearing. If

you disobey this Order, the police 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 $1,000.00 and/or up to six months in jail under 23 Pa.C.S. §

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. You must relinquish any firearm, other weapon, ammunition, or any firearm license listed herein 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]

FORM 21.6 Order to Vacate

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. : PROTECTION FROM ABUSE

DEFENDANT :

AND NOW, this ____________ day of __________________, 20______, it is hereby ORDERED and DECREED

that the TEMPORARY ORDER in the above-captioned matter is hereby VACATED and the action is dismissed

with/without prejudice.

BY THE COURT

__________________

FORM 21.7 Final Order (by Consent or Otherwise)

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. : PROTECTION FROM ABUSE

DEFENDANT :

FINAL ORDER OF COURT

Defendant's Name: __________________

Defendant's Date of Birth: __________________

Defendant's Social Security Number: __________________

Names and Dates of Birth of All Protected Persons, including Plaintiff and minor children:

__________________

Names Dates of Birth

__________________ _____________

_____

CHECK ALL THAT APPLY:

Plaintiff or Protected Person(s) is/are:

[ ] spouse or former spouse of Defendant

[ ] parent of a common 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 biological parenthood) of Defendant

[ ] current or former cohabitant (person who lives with) 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:

[ ] 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 the Plaintiff or any other protected person in any place where they might be found.

[ ] 2. Defendant is completely evicted and excluded from the resident at [INSERT 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 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

the Plaintiff, or any other person protected under this Order, at any location, including but not limited to any contact at

the 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 the Plaintiff, or any other person

protected under this Order, by telephone or by any other means, including through third persons.

[ ] 5. Custody of the minor children, [INSERT NAMES OF THE CHILDREN SUBJECT TO THE PROVISION

OF THIS PARAGRAPH], shall be as follows: (STATE TO WHOM PRIMARY PHYSICAL CUSTODY AWARDED;

STATE TERMS OF PARTIAL CUSTODY OR VISITATION, IF ANY.)

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

Check all that apply: [ ] Defendant shall relinquish to the sheriff all firearms and firearm licenses owned or possessed by

Defendant. [ ] Defendant is directed to relinquish to the sheriff any firearm, other weapon, or ammunition listed in

Petitioner's Attachment A, and any firearms license Defendant may possess. Defendant may relinquish any firearms,

other weapons, or ammunition to the sheriff. As an alternative, Defendant may relinquish firearms, other weapons,A

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, 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 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.

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

[ ] 9. Defendant is directed to pay temporary support for (INSERT 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 order is entered

by this Court. However, this order shall lapse automatically if the 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 the 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, 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).

[ ] 11. Defendant shall pay $____________ to Plaintiff as compensation for Plaintiff's out-of-pocket losses, which

are as follows:

[ ] Plaintiff is granted leave to present a petition, with appropriate notice to Defendant, to [INSERT 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 out-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 SUPERSEDES [ ] ANY PRIOR PFA ORDER AND [ ] ANY PRIOR ORDER RELATING TO

CHILD CUSTODY.

13. All provisions of this order shall expire in three years, on (INSERT 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.

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 LAW ENFORCEMENT OFFICIALS

The police who have jurisdiction over the Plaintiff's residence OR any location where a violation of this order

occurs OR where the Defendant may be located, shall enforce this order. 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. 23 Pa. C.S. § 6113.

Subsequent to an arrest, the police officer shall seize all weapons used or threatened to be used during the violation

of the protection order or during prior incidents of abuse. The [INSERT THE APPROPRIATE NAME OR TITLE] shall

maintain possession of the weapons until further order of this Court.

When the Defendant is placed under arrest for violation of the order, the 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 OR the Plaintiff. Plaintiff's presence and signature are not required to

file this complaint.

If sufficient grounds for violation of this order are alleged, the Defendant shall be arraigned, bond set, 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)

FORM 21.8 Complaint for Indirect Criminal Contempt

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT : PROTECTION FROM ABUSE

COMPLAINT FOR INDIRECT CRIMINAL CONTEMPT FOR VIOLATION OF PROTECTION FROM

ABUSE ORDER

AND NOW, comes the Plaintiff, and avers as follows:

1. Plaintiff is __________________, who resides at (address) [or, whose address is not disclosed as such disclosure

would endanger him/her and/or his/her family].

2. Defendant is __________________, who resides at (address).

3. On (date) a Protection from Abuse Order was entered by this Honorable Court. A true and correct copy of said

Order is attached hereto as an Exhibit.

4. On (date) the Defendant violated said Order by (give specifics, including location).

5. The aforesaid acts committed by Defendant were in violation of the Protection from Abuse Order entered in

accordance with the Protection from Abuse Act, 23 Pa. C.S.A. §§ 6101 et seq.

6. Plaintiff requests that a warrant of arrest be issued for the Defendant and that he/she be required to answer the

charges made above.

__________________

Signature of Affiant

Date: ____________

[Verification]

FORM 21.9 Order re Criminal Contempt

IN THE COURT OF COMMON PLEAS

OF __________________, COUNTY, PENNSYLVANIA

PLAINTIFF : No.

DEFENDANT : PROTECTION FROM ABUSE

ORDER

AND NOW, this ____________ day of __________________, 20______, it is hereby Ordered, Adjudged and

Decreed that Defendant, __________________, is guilty of indirect criminal contempt of the Protection from Abuse

Order entered on behalf of Plaintiff, __________________, in the aforesaid matter, and is sentenced to serve

____________ days in __________________. Additionally, all provisions of Plaintiff's Protection from Abuse Order

are hereby extended for one year from the date of this Order.

BY THE COURT:

__________________

FORM 22.12C Appearance of Child Support Creditor or Representative

IN THE UNITED STATES BANKRUPTCY COURT FOR

THE __________________ DISTRICT OF PENNSYLVANIA

IN RE: Chapter ____________ Case

__________________ Debtor :

Social Security No(s):

Employer's Tax

Identification No(s).

Bankruptcy No.

APPEARANCE OF CHILD SUPPORT CREDITOR OR REPRESENTATIVE

I certify under penalty of perjury that I am a child support creditor of the above-named debtor, or the authorized

representative of such child support creditor, with respect to the child support obligation which is set out below.

Name:

Organization:

Address:

Telephone Number:

__________________

Date

X__________________

Child Support Creditor

Authorized Representative

Summary of Child Support Obligation

Amount currently due per

week or per month: on a

Amount owed primary

child support creditor

continuing basis: (balance not assigned):

$____________

(per week) (per month)

$____________

If Child Support has been

assigned:

Amount in Arrears: Amount of Support which

is owed under assignments:

$____________ $____________

Attach an itemized statement of account

FORM 22.24 Stipulation and Agreed Order for a Qualified Medical Child Support Order

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

STIPULATION AND AGREED ORDER FOR A QUALIFIED MEDICAL CHILD SUPPORT ORDER

AND NOW, this ____________ day of __________________, 20______ it is hereby STIPULATED and

AGREED to by and between the above-captioned parties as follows:

1. This Agreement and Order is made pursuant to the Domestic Relations Law of Pennsylvania, specifically 23 Pa.

C.S. § 4326.

2. __________________ (hereinafter ``the Participant'') is a participant in (Company/Policy No./Group No.) and

__________________ (hereinafter ``the Plan'').

3. The current, last known mailing address of the Participant is __________________.

4. The Participant's social security number is __________________.

5. Pursuant to this Court's Order dated __________________, the Participant has an obligation to provide health

insurance coverage under the Plans for his spouse, __________________, and their child, __________________

(hereinafter referred to as ``the Alternate Recipients'').

6. The name, date of birth, and social security number of the Alternate Recipients are:

NAME DATE OF

BIRTH

SOCIAL SECURITY

NUMBER

___________

_______

____________

______

__________________

7. The mailing address of the Alternate Recipients is __________________.

8. By virtue of this Order, the Plan shall provide health insurance coverage to the Alternate Recipients for so long

as the Participant is enrolled under the Plan. The Plan's obligation to provide such health insurance coverage shall

terminate earlier by agreement of the parties or by Order of Court.

9. The following is a description of the coverage type the Plan shall provide to the Alternate Recipient, or the

means by which such coverage shall be determined: Medical, Prescription and Hospitalization and, if available, Dental,

provided that this Order shall not require the Plan to provide any type of form of benefit or any option not otherwise

provided under the Plan.

10. This Order does not create a separate obligation by the Participant to provide health insurance coverage to the

Alternate Recipient. The Participant's obligation to provide this health insurance coverage derives from and is limited to

the Order entered on __________________.

11. Pursuant to 23 Pa. C.S. § 4326(g), the Plan shall receive, process and pay all claims for services relating to the

Alternate Recipients directly from/to __________________ and shall in all other respects comply with the terms of

Section 4326(g).

12. This Order shall in no way adversely affect Participant's right to communicate with and receive relevant

information regarding coverage and administration of the Plan, as such right existed prior to the date of entry of this

Order.

13. The parties shall submit this Stipulation and Agreed Order to the Court for approval and entry as an Order.

14. This Stipulation and Agreed Order shall be effective immediately. The parties shall promptly submit this

Stipulation and Agreed Order to the Plan Administrators for implementation. The parties shall promptly notify the Plan

of any change in their addresses or the addresses of the Alternate Participant from those set forth in the Stipulation and

Agreed Order.

15. The Court retains jurisdiction to amend this Order as might be necessary to establish or maintain its status. The

parties shall execute any further documents which might be required to ensure that the terms and intent of this Order are

honored.

__________________

Attorney for Plaintiff

__________________

Plaintiff

__________________

Attorney for Defendant

__________________

Defendant

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

PLAINTIFF : No.

v. :

DEFENDANT

ORDER

AND NOW, this ____________ day of __________________, 20______ is hereby ORDERED and DECREED

that the Stipulation annexed hereto between Plaintiff, __________________, and Defendant, __________________, is

APPROVED and entered as an Order of Court:

1.This Agreement and Order is made pursuant to the Domestic Relations Law of Pennsylvania,

specifically 23 Pa. C.S. § 4326.

2.__________________ (hereinafter ``the Participant'') is a participant in __________________

(hereinafter ``the Plan'').

3.The current last known mailing address of the Participant is __________________.

4.The Participant's social security number is __________________.

5.Pursuant to this Court's Order dated __________________, the Participant has an obligation to

provide health insurance coverage under the Plan for his/her spouse and child (hereinafter referred to as

``the Alternate Recipients'').

6.The name, date of birth and social security number of the Alternate Recipient is:

NAME DATE OF

BIRTH

SOCIAL SECURITY

NUMBER

___________

_______

____________

______

__________________

7.The mailing address of the Alternate Recipient is:

8.By virtue of this Order, the Plan shall provide health insurance coverage to the Alternate

Recipients for so long as the Participant is enrolled under the Plan. The Plan's obligation to provide such

health insurance coverage shall terminate earlier by agreement of the parties or by Order of Court.

9.The following is a description of the coverage type the Plan shall provide to the Alternate

Recipient, or the means by which such coverage shall be determined: Medical, Prescription and

Hospitalization and, if available, Dental, provided that this Order shall not require the Plan to provide

any type of form of benefit or any option not otherwise provided under the Plan.

10.This Order does not create a separate obligation by the Participant to provide health insurance

coverage to the Alternate Recipient. The Participant's obligation to provide this health insurance

coverage derives from and is limited to the Order entered on __________________.

11.Pursuant to 23 Pa. C.S. § 4326(g), the Plan shall receive, process and pay all claims for services

relating to the Alternate Recipient directly from/to __________________ and shall in all other respects

comply with the terms of Section 4326(g).

12.This Order shall in no way adversely affect __________________ right to communicate with and

receive relevant information regarding coverage and administration of the Plans, as such right existed

prior to the date of entry of this Order.

13.The parties shall submit this Stipulation and Agreed Order to the Court for approval and entry as

an Order.

14.This Stipulation and Agreed Order shall be effective immediately. The parties shall promptly

submit this Stipulation and Agreed Order to the Plan Administrators for implementation. The parties

shall promptly notify the Plan of any change in their addresses or the addresses of the Alternate

Participant from those set forth in the Stipulation and Agreed Order.

15.The Court retains jurisdiction to amend this Order as might be necessary to establish or maintain

its status. The parties shall execute any further documents which might be required to ensure that the

terms and intent of this Order are honored.

BY THE COURT:

__________________

FORM 24.3 Petition for the Appointment of Guardian of Estate of a Minor to Nominate a Party to Bring

Litigation

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

[ORPHANS' COURT DIVISION]

IN RE ESTATE OF : No.

[NAME(S) OF

CHILD(REN)], (A) MINOR(S) :

DECREE

AND NOW, this ____________ day of __________________, 20______, upon consideration of the annexed

Petition for the Appointment of a Guardian of the Estate of Minors, [Name(s) of Child(ren)], to Nominate a Party to

Bring Litigation, it is hereby ORDERED and DECREED that __________________, is appointed Guardian of the

Estate of said minor(s) for the purpose of bringing litigation on behalf of said minor(s). BY THE COURT:

__________________

IN THE COURT OF COMMON PLEAS

OF __________________ COUNTY, PENNSYLVANIA

[ORPHANS' COURT DIVISION]

IN RE ESTATE OF : No.

[NAME(S) OF

CHILD(REN)], (A) MINOR(S)

PETITION FOR THE APPOINTMENT OF A GUARDIAN OF THE ESTATE OF (A) MINOR(S) TO

NOMINATE A PARTY TO BRING LITIGATION

TO THE HONORABLE, THE JUDGES OF SAID COURT:

Petitioner, __________________, by and through her attorney, __________________, files this Petition for the

Appointment of a Guardian of the Estate of (A) Minor(s) to Nominate a Party to Bring Litigation, and in support

thereof, avers the following:

1. Petitioner is __________________ (``Wife''), Plaintiff in the abovecaptioned divorce action. Wife currently

resides at __________________.

2. Respondent is __________________ (``Husband''), Defendant in the above-captioned divorce action. Husband

currently resides at __________________.

3. The parties hereto were married on __________________.

4. On or about __________________, Wife filed a Complaint in Divorce against Husband, requesting, among other

things, confirmation of legal and physical custody of the parties' minor child(ren), __________________, equitable

distribution of marital property, and other economic relief.

5. On or about __________________, Wife received an investigative report from Child Protective Services

indicating that the agency determined that the parties' minor child(ren), __________________ __________________,

had been abused by Husband. A true and correct copy of this investigative report is marked Exhibit ``A,'' attached

hereto and made part hereof.

6. Wife believes, and therefore avers, that due to the investigative report from Child Protective Services the minor

child(ren), __________________, has/have a potential domestic tort action against Husband, including, but not limited

to, assault, battery, intentional infliction of emotional distress, negligent infliction of emotional distress, and an implied

private civil cause of action based upon the violation of a criminal statute.

7. Wife believes, and therefore avers, that good cause exists for the appointment of a guardian to take whatever

legal action is necessary and appropriate to protect and advance the minor child's/ children's best interests and welfare in

bringing said litigation. Wife proposes that __________________ be appointed guardian to represent the minor

child(ren). __________________'s address is: __________________ __________________.

8. No other guardian has been appointed for the estate of the minor child(ren).

9. The proposed guardian has no interest adverse to the minor child(ren). The consent of the proposed guardian is

marked Exhibit ``B,'' attached hereto and made part hereof.

WHEREFORE, Petitioner, __________________, respectfully requests that this Honorable Court appoint

__________________, as guardian of the estate of the minor child(ren), __________________, for the purpose of

bringing litigation on behalf of said minor(s).

__________________

, Esquire

Attorney for Petitioner

[Verification]

FORM 105.01-1 Complaint for Support

Plaintiff ) TERM,

v. ) (year)

Defendant ) NO.

COMPLAINT FOR SUPPORT

1. The Plaintiff resides at __________________, in __________________ County. Plaintiff's Social Security

Number is ____________, and date of birth is __________________.

2. The Defendant resides at __________________, in __________________ County. Defendant's Social Security

Number is ____________, and date of birth is __________________.

3. (a) Plaintiff and defendant were married on __________________ (date), at __________________.

(b) Plaintiff and defendant were separated on __________________.

4. Plaintiff and defendant are the parents of the following children:

(a) Born of the marriage:

Name Birth Date Age Residence

________

__________

________

______

__________________

(b) Born out of wedlock:

Name Birth Date Age Residence

________

__________

________

______

__________________

__ ______

5. Plaintiff seeks support for the following persons: __________________

6. (a) Plaintiff is (not) receiving public assistance in the amount of $____________ per __________________ for

the support of __________________.

(b) Plaintiff is receiving additional income in the amount of $____________ from __________________.

7. A previous support order was entered against the defendant on __________________ (date ), in an action at

__________________ (Court, term, and docket no.) in the amount of $____________ for the support of

__________________.

There are (no) arrearages in the amount of $ ____________ The order has (not) been terminated.

8. Plaintiff last received support from defendant in the amount of $____________ on __________________.

WHEREFORE, plaintiff requests that an order be entered against defendant and in favor of plaintiff and the

aforementioned child(ren) for reasonable support and medical coverage.

I verify that the statements made in this complaint are true and correct. I understand that false statements herein are

made subject to the penalties of 18 Pa. Cons. Stat. § 4904, relating to unsworn falsification to authorities.

________________________

Plaintiff

NOTICE

Guidelines for child and spousal support, and for alimony pendente lite have been prepared by the Court of

Common Pleas and are available for inspection in the office of the Domestic Relations Section, __________________

(address).

FORM 105.01-2 Order of Court for Conference

You, __________________, defendant, are ordered to appear at __________________ before

__________________, a conference officer of the Domestic Relations Section, on the ____________ day of

__________________, at ____________ (time), for a conference, after which the conference officer may recommend

that an order for support be entered against you.

You are further ordered to bring to the conference:

1. A true copy of your most recent federal income tax return, including W-2s, as filed;

2. Your pay stubs for the preceding six months;

3. The Income and Expense Statement, if required, attached to this order, completed as required by Pa. R.C.P.

1910.11(c);

4. Verification of child care expenses; and

5. Proof of medical coverage that you may have or may have available to you.

If you fail to appear for the conference or to bring the required documents, the court may issue a warrant for your

arrest and/or enter an interim support order. If paternity is an issue, the court shall enter an order establishing paternity.

THE APPROPRIATE COURT OFFICER MAY ENTER AN ORDER AGAINST EITHER PARTY BASED

UPON THE EVIDENCE PRESENTED WITHOUT REGARD TO WHICH PARTY INITIATED THE SUPPORT

ACTION.

Date of Order: ________________________

YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT

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.

[Name]

[Address]

[Telephone Number]

AMERICANS WITH DISABILITIES ACT OF 1990

The Court of Common Pleas of __________________ County is required by law to comply with the Americans

with 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.

FORM 105.01-4 Order of Court-Conference on Modification of Existing Support Order

You, __________________, respondent, have been sued in court to modify an existing support order. You are

ordered to appear in person at __________________ on __________________ (date), at ____________ (time), for a

conference and to remain until dismissed by the court. If you fail to appear as provided in this order, an order for

modification may be entered against you.

You are further ordered to bring to the conference:

1. A true copy of your most recent federal income tax return, including W-2s, as filed;

2. Your pay stubs for the preceding six months;

3. The Income and Expense Statement, if required, attached to this order completed as required by Pa. R.C.P.

1910.11(c);

4. Verification of child care expenses; and

5. Proof of medical coverage that you may have or may have available to you.

THE APPROPRIATE COURT OFFICER MAY MODIFY OR TERMINATE THE EXISTING ORDER IN ANY

MANNER BASED UPON THE EVIDENCE PRESENTED.

Date of Order: ________________________

YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE AND REPRESENT

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.

[Name]

[Address]

[Telephone Number]

________________________

(Name)

________________________

(Address)

________________________

(Telephone Number)

AMERICANS WITH DISABILITIES ACT OF 1990

The Court of Common Pleas of __________________ County is required by law to comply with the Americans

with 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.

FORM 105.01-5 Income Statements

Although we have included the standard state-wide Income Statements and Expense Statements, you should check

with the county as some prefer their local form to be used.

The revisions to the Support Guidelines have changed the use of the Income and Expense Statements. Prior to the

revisions of the Guidelines, a litigant was required to fill out a combined Income and Expense Statement. Under the

revised Guidelines, in all cases, the parties must fill out the Income Statement (and Supplemental Income Statement if

the party is self-employed or salaried by a business which he or she is an owner in whole or in part). The Income

Statement is Form 105.01-5 below and can also be found at Pa. R.C.P. 1910.27.

The revised Support Guidelines also provide two different Expense Statements to be used depending on where the

case is a Guideline case, where the parties' combined net monthly income is $20,000.00 or less, or a Melzer case, where

the parties' combined monthly net incomes exceed $20,000.00.

If the case is a Guideline case, the Expense Statement under Pa. R.C.P. 1910.27(c)(2)(A) is only necessary if a

party is claiming unusual needs and expenses that may warrant a deviation from the guideline amount of support

pursuant to Rule 1910.16-5 or if the party is seeking apportionment of expenses pursuant to Rule 1910.16-6. The

Guideline provides that the parties must provide receipts or other verification of expenses claimed on the Expense

Statement. The Guideline Expense Statement is Form 105.01-6 below.

If the case is a Melzer case, the Guideline provides that the parties shall exchange the Melzer Expense Statement no

less than 5 business days prior to the support conference. The parties shall also exchange receipts or other verification of

the expenses listed on the Statement at that time. The Melzer Expense Statement is Form 105.01-6.1 below and is also

located at Rule 1910.27(c)(2)(B).

Click here to view image.

FORM 105.01-7 Order for Earnings Report, Health Insurance Information, and Subpoena

TO:

AND NOW, this ____________ day of __________________, 20______ since it appears that

__________________ is employed by you, and it is necessary that the court obtain earnings and health insurance

information relating to the above-named individual in order to adjudicate a matter of support, IT IS HEREBY

ORDERED AND DECREED that you supply the court with the information required by the enclosed Earnings Report

and Health Insurance Coverage Report and file it with the court within fifteen (15) days of the date of the Order.

If you fail to supply the information required by this order, a subpoena will issue requiring you to attend court and

bring the material with you, or other appropriate sanctions will be imposed by the court.

By the Court:

________________________

FORM 105.01-7.1 Health Insurance Coverage Information Required by the Court

This form must be completed and returned to the domestic relations section.

IF YOU FAIL TO PROVIDE THE INFORMATION REQUESTED, THE COURT MAY FIND THAT YOU ARE

IN CONTEMPT OF COURT.

Do you provide insurance coverage for the dependents named below? __________________. (Check each type of

insurance that you provide).

Type of Coverage

Full Name: ________________________

SS#: ______________________________ Hospitalization______ Medical______ Dental______ Eye______

Prescription______ Other

Provide the following information for all types of insurance you maintain, whether or not any of the above-named

dependents is covered at this time:

Insurance Company (Provider): __________________Group #: ____________ Plan #: ____________

Policy #: ____________

Cost of Dependent Coverage: __________________

Insurance Company (Provider): __________________Group #: ____________ Plan #: ____________

Policy #: ____________

Cost of Dependent Coverage: __________________

Insurance Company (Provider): __________________Group #: ____________ Plan #: ____________

Policy #: ____________

Cost of Dependent Coverage: __________________

Insurance Company (Provider): __________________Group #: ____________ Plan #: ____________

Policy #: ____________

Cost of Dependent Coverage: __________________

If the above-named dependents are not currently covered by insurance, please state the earliest date coverage could

be provided: __________________

FORM 105.01-7.2 Earnings Report

Employer: ____________

Re: ____________ (Name)

Social Security Number: ____________

Support Action No: ____________

EARNINGS REPORT

To the Employer:

Furnish earnings information for the above-named employee for each pay period during the last six months. It is

preferred that you attach a photocopy of your records containing the earnings information requested. Attach a copy of

the employee's most recent W-2 form.Payroll Number:__________________

Nature of Employment:__________________

Payroll Period Ending:__________________

Date of Pay:__________________

Gross Pay: __________________

Deductions: __________________

Federal Withholding: __________________

Social Security: __________________

Local Wage Tax: __________________

State Income Tax: __________________

Retirement: __________________

Savings Bonds: __________________

Credit Union: __________________

Life Insurance: __________________

Health Insurance: __________________

Other (specify): __________________

Net Pay:__________________

Hours Worked:__________________

[VERIFICATION]

Date:________________________

Signed by:________________________

Position: ________________________

FORM 105.01-7.3 Order of Attachment of Income

To:____________ (name of employer)

Pursuant to Pennsylvania law, the income of ____________ (name), defendant, ________________________

(payroll or social security number), __________________ (address), is hereby attached to the following extent:

You are, pursuant to this order, directed to pay to the office of Pa. SCDU at __________________ Pa. SCDU, P. O.

Box 69112, Harrisburg, PA 17106-9112, until further order of the court, the sum of $____________ per ____________

out of the income due the defendant.

Checks should be made payable to Pa. SCDU and sent within seven (7) days of date defendant is paid.

________________________

Date of Order: ________________________

FORM 105.01-7.5 Notice of Attachment

__________________ TO __________________, Defendant Obligor:

No less than 10 days from the date of this notice, the court will issue an attachment against your income for failure

to pay support pursuant to an order entered on __________________ (date). The records of the Domestic Relations

Section establish that as of __________________ (date) you are in arrears in the sum of $ ____________ which is an

amount equal to or greater than one month's support obligation.

You are notified as follows:

1. The amount of income to be withheld is $ ____________;

2. This attachment shall apply to present and future income;

3. Pennsylvania law provides that you have the right to contest the order of attachment based only on the following

mistakes of fact:(i) You are not more than one month's payments in arrears;(ii) The amount to be attached is more than

the amount allowed by law; or(iii) You are not the person who is to pay the support; and

4. Pennsylvania law requires that there be an attachment of your income if you are more than one month's payments

in arrears regardless of the reason why you are in arrears unless one of the mistakes of fact listed in paragraph 3, above,

has occurred.

5. The attachment shall occur no less than 10 days after the date of the issuance of this advance notice.

To contest the proposed order of attachment, you must appear in person at the Domestic Relations Section of the

Court of Common Pleas of __________________ County, __________________ (address), no later than 10 days after

the date of this advance notice. It will be determined at that time if a mistake of fact listed in paragraph 3 has occurred.

If so, the order of attachment shall be modified accordingly.

YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER

OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT

WHERE YOU CAN GET LEGAL HELP.

________________________

(Name)

________________________

(Address)

________________________

(Telephone Number)

FORM 105.01-8 Order of Court-Support (Final/Temporary/Modified)

AND NOW, on __________________ (date), based on the court's determination that payee's monthly net income is

$ ____________, and payor's monthly net income is $ ____________, it is hereby ordered that the payor pay to the

Domestic Relations Section, Court of Common Pleas, __________________ Dollars ($ ____________) a month

payable (weekly/biweekly/semimonthly/monthly) as follows: __________________. __________________ Arrears set

at $ ____________ as of __________________ are due in full IMMEDIATELY. Contempt proceedings, credit bureau

reporting and tax refund offset certification will not be initiated, and judgment will not be entered, as long as payor pays

$ ____________ on the arrears on each payment date. Failure to make each payment on time and in full will cause all

arrears to become subject to immediate collection by all of the means listed above.

For the support of

________________________________________________________________________________________________

Said money to be turned over by the Domestic Relations Section to __________________.

Payments must be made __________________ (state acceptable forms of payment). All checks and money orders

must be made payable to __________________ (name of entity to whom checks should be made payable) and mailed to

__________________(name of office) at __________________ (mailing address). Each payment must bear your

(file/case/folio/domestic relations) number in order to be processed. Do not send cash by mail.

Unreimbursed medical expenses are to be paid ____________% by defendant and ____________% by plaintiff.

(Plaintiff/Defendant/Neither) to provide medical insurance coverage. Within 30 days after the entry of this order, the

(plaintiff/defendant) shall submit to the person having custody of the child(ren) written proof that medical insurance

coverage has been obtained or that application for coverage has been made. Proof of coverage shall consist, at a

minimum, of (1) the name of the health care coverage provider(s); (2) any applicable identification numbers; (3) any

cards evidencing coverage; (4) the address to which claims should be made; (5) a description of any restrictions on

usage, such as prior approval for hospital admissions, and the manner of obtaining approval; (6) a copy of the benefit

booklet or coverage contract; (7) a description of all deductibles and co-payments; and (8) five copies of any claim

forms.

IMPORTANT LEGAL NOTICE

PARTIES MUST WITHIN SEVEN DAYS INFORM THE DOMESTIC RELATIONS SECTION AND THE

OTHER PARTIES IN WRITING OF ANY MATERIAL CHANGE IN CIRCUMSTANCES RELEVANT TO THE

LEGAL ISSUE OF SUPPORT OR THE ADMINISTRATION OF THE SUPPORT ORDER INCLUDING BUT NOT

LIMITED TO LOSS OR CHANGE OF INCOME OR EMPLOYMENT AND CHANGE OF PERSONAL ADDRESS

OR CHANGE OF ADDRESS OF ANY CHILD RECEIVING SUPPORT. A PARTY WHO WILLFULLY FAILS TO

REPORT A MATERIAL CHANGE IN CIRCUMSTANCE MAY BE ADJUDGED IN CONTEMPT OF COURT, AND

MAY BE FINED OR IMPRISONED.

PENNSYLVANIA LAW PROVIDES THAT ALL SUPPORT ORDERS SHALL BE REVIEWED AT LEAST

ONCE EVERY THREE (3) YEARS IF SUCH A REVIEW IS REQUESTED BY ONE OF THE PARTIES. IF YOU

WISH TO REQUEST A REVIEW AND ADJUSTMENT OF YOUR ORDER, YOU MUST DO THE FOLLOWING:

__________________. AN UNREPRESENTED PERSON WHO WANTS TO MODIFY (ADJUST) A SUPPORT

ORDER SHOULD __________________. (insert instructions for local court.) ALL CHARGING ORDERS FOR

SPOUSAL SUPPORT AND ALIMONY PENDENT ELITE, INCLUDING UNALLOCATED ORDERS FOR CHILD

AND SPOUSAL SUPPORT OR CHILD SUPPORT AND ALIMONY PENDENTE LITE SHALL TERMINATE

UPON THE DEATH OF THE PAYEE.

A MANDATORY INCOME ATTACHMENT WILL ISSUE UNLESS THE DEFENDANT IS NOT IN

ARREARS IN PAYMENT IN AN AMOUNT EQUAL TO OR GREATER THAN ONE MONTH'S SUPPORT

OBLIGATION AND (1) THE COURT FINDS THAT THERE IS GOOD CAUSE NOT TO REQUIRE IMMEDIATE

INCOME WITHHOLDING; OR (2) A WRITTEN AGREEMENT IS REACHED BETWEEN THE PARTIES WHICH

PROVIDES FOR AN ALTERNATE ARRANGEMENT.

DELINQUENT ARREARAGE BALANCES MAY BE REPORTED TO CREDIT AGENCIES. ON AND AFTER

THE DATE IT IS DUE, EACH UNPAID SUPPORT PAYMENT SHALL CONSTITUTE A JUDGMENT AGAINST

YOU.

IT IS FURTHER ORDERED that, on payor's failure to comply with this order, payor may be arrested and brought

before the court for a contempt hearing; payor's wages, salary, commissions, and/or income may be attached in

accordance with law; this order will be increased without further hearing to $ ____________ a month until all

arrearages are paid in full. Payor is responsible for court costs and fees.

Copies delivered to parties on __________________ (date).

Consented:

__________________ __________________

Plaintiff Plaintiff's Attorney

__________________ __________________

Defendant Defendant's Attorney

By the Court:

________________________

FORM 105.05-1 Order of Court for Conference

(caption including docket No. and PACSES Case No.)

You, ____________, Defendant, are ordered to appear in person at the Domestic Relations Office, ____________

(address), on ____________ at ____________ for a conference/hearing after which the conference officer may

recommend that an order for support be entered against you.

BOTH PARTIES ARE ORDERED TO BRING TO THE CONFERENCE AN ORIGINAL AND TWO COPIES

OF THE FOLLOWING:

1. A true copy of your most recent Federal Income Tax Return, including W-2s, as filed;

2. Your pay stubs for the preceding six months;

3. The Income Statement and the appropriate Expense Statement, if required, attached to this order, completed as

required by Rule 1910.11(c);

(4) A verification of child care expenses;

(5) Proof of medical coverage which you may have or may have available to you;

(6) Information relating to professional licenses;

(7) Other __________________

IF YOU FAIL TO APPEAR OR TO BRING THE REQUIRED DOCUMENTS, THE COURT MAY ISSUE A

WARRANT FOR YOUR ARREST AND/OR ENTER AN INTERIM SUPPORT ORDER. IF PATERNITY IS AN

ISSUE, THE COURT SHALL ENTER AN ORDER ESTABLISHING PATERNITY.

THE APPROPRIATE COURT OFFICER MAY ENTER AN ORDER AGAINST EITHER PARTY BASED ON

THE EVIDENCE PRESENTED WITHOUT REGARD TO WHICH PARTY INITIATED THE SUPPORT ACTION.

YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE-HEARING AND

REPRESENT 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.

LAWYER REFERRAL SERVICE

100 W. AIRY STREET REAR

NORRISTOWN, PA 19401-4724

(610) 279-9660

AMERICANS WITH DISABILITIES ACT OF 1990

The Court of Common Pleas of Montgomery County is required by law to comply with the Americans with

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 at: (610) 378-3646. All arrangements

must be made at least 72 hours prior to any hearing or business before the court. You must attend the scheduled hearing.

FORM 105.05-2 Order for Support Hearing

(Caption)

ORDER OF COURT

You, __________________ (name), Defendant, are ordered to appear at the Montgomery County Conciliator

Office, c/o Master's Support, 3 Penn Court, Swede and Penn Streets, Norristown, Pennsylvania, before the Hearing

Officer assigned on ____________ (date) at __________________.m. for a hearing.

YOU ARE FURTHER REQUIRED TO BRING TO THE HEARING:

1. A true copy of your most recent Federal Income tax return, as filed, (including Corporate Return and Profit and

Loss Statement, if applicable and W-2s).

2. Your pay stubs for the preceding six months.

3. The Income Statement and appropriate Expense Statement, if required, attached to this Order, completed as

required by Rule 1910.11(c).

4. Bring verification of child care expenses.

5. Proof of medical coverage which you may have available to you.

6. Information relating to professional licenses.

7. Other.

If you fail to appear for the conference/hearing or to bring the required documents, the court may issue a warrant

for your arrest and/or enter an interim court order. If paternity is an issue, the court shall enter an order establishing

paternity.

THE APPROPRIATE COURT OFFICE MAY ENTER AN ORDER AGAINST EITHER PARTY BASED UPON

THE EVIDENCE PRESENTED WITHOUT REGARD TO WHICH PARTY INITIATED THE SUPPORT ACTION.

BY THE COURT:

Date of Order

____________

__________________ Judge

YOU HAVE THE RIGHT TO A LAWYER, WHO MAY ATTEND THE CONFERENCE-HEARING AND

REPRESENT 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.

LAWYER REFERRAL SERVICE

100 W. AIRY STREET REAR

NORRISTOWN, PA 19401-4724

(610) 279-9660

AMERICANS WITH DISABILITIES ACT OF 1990

The Court of Common Pleas of Montgomery County is required by law to comply with the Americans with

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 at: (610) 378-3646. All arrangements

must be made at least 72 hours prior to any hearing or business before the court. You must attend the scheduled hearing.

FORM 105.05-6 ORDER OF COURT-SUPPORT (FINAL/TEMPORARY/MODIFIED)

(Caption)

AND NOW, on ____________ (date), based on the court's determination that payee's monthly net income is

$____________, and payor's monthly net income is $____________, it is herby ordered that the payor pay to Pa.

SCDU, ____________ Dollars ($____________) a month payable (weekly/biweekly/semimonthly/monthly) as follows:

____________. Contempt proceedings, credit bureau reporting and tax refund offset certification will not be initiated,

and judgment will not be entered, as long as payor pays $____________ on the arrears on each payment date. Failure to

make each payment on time and in full will cause all arrears to become subject to immediate collection by all of the

means listed above.

For the support of: ____________, ____________, and ____________.

Said money to be turned over by Pa. SCDU to ____________. This order is effective on ____________ (date) and

amends the previous order of ____________ (date). Payments must be made by cash, money order or check. All checks

and money orders must be made payable to Pa. SCDU and mailed to Pa. SCDU, Box 659112, Harrisburg, PA

17106-9112. Each payment must bear your case number in order to be processed. Do not send cash by mail.

Unreimbursed medical expenses are to be paid ____________ percent by defendant and ____________ percent by

plaintiff. The plaintiff is responsible to pay the first $250.00 annually (per child and/or spouse) in unreimbursed

expenses. (Plaintiff/Defendant/Neither) to provide medical insurance coverage. Within 30 days after the entry of this

order, the (Plaintiff/Defendant) shall submit to the person having custody of the child(ren) written proof that medical

insurance coverage has been obtained or that application for coverage has been made. Proof of coverage shall consist, at

a minimum, of (1) the name of the health care coverage provider(s); (2) any applicable identification numbers; (3) any

cards evidencing coverage; (4) the address to which claims should be made; (5) a description of any restrictions on

usage, such as prior approval for hospital admissions, and the manner of obtaining approval; (6) a copy of the benefit

booklet or coverage contract; (7) a description of all deductibles and co-payments; and (8) five copies of any claim

forms.

IMPORTANT LEGAL NOTICE

Parties must within seven days inform the domestic relations section and the other parties in writing of any material

change in circumstances relevant to the legal issue of support or the administration of the support order including but

not limited to loss or change of income or employment and change of personal address or change of address of any

child receiving support. A party who willfully fails to report a material change in circumstance may be adjudged in

contempt of court, and may be fined or imprisoned.

Pennsylvania law provides that all support orders shall be reviewed at least once very three (3) years if such a

review is requested by one of the parties. If you wish to request a review and adjustment of your order, you must do the

following: ____________. An unrepresented person who wants to modify (adjust) a support order should obtain a

petition to modify from the domestic relations office and should file it with the domestic relations office.

A mandatory income attachment will issue unless the defendant is not in arrears in payment in an amount equal to

or greater than one month's support obligation and (1) the court finds that there is good cause not to require immediate

income withholding; or (2) a written agreement is reached between the parties, which provides for an alternate

arrangement.

Delinquent arrearage balances may be reported to credit agencies. On and after the date it is due, each unpaid

support payment shall constitute a judgment against you.

IT IS FURTHER ORDERED that, on payor's failure to comply with this order, payor may be arrested and brought

before the court for a contempt hearing; payor's wages, salary, commissions, and/or income may be attached in

accordance with law; payment on arrears will be increased without further hearing by ____________ a month until all

arrearages are paid in full. Payor is responsible for court costs and fees.

Copies delivered to parties on ____________ (date).

Consented:

__________________

__________________ __________________

Conference Officer Plaintiff's Attorney

Plaintiff

__________________ __________________

Defendant Defendant's Attorney

AND NOW, this ____________ day of ____________, 20____________, upon consideration of the support

recommendation/agreement recited herein, the same is adopted and entered as an Order of Court.

By the Court,

________________________

FORM 105.05-7 Affidavit to Complaint

The above Complainant, __________________ (name) being duly sworn, deposes and says that he (or she) has

read the foregoing Complaint, and that the statements made therein are true and correct.

________________________

Complainant

FORM 105.05-8 Affidavit of Indigency

Personally appeared before me, the undersigned authority, __________________ (name), Complainant in the

above matter, who, being duly sworn according to law, deposes and says that he (or she) is without funds to obtain an

attorney or pay the costs in the foregoing matter and is in necessitous circumstances.

________________________

Complainant

FORM 105.05-9 Affidavit by Public or Private Agency

Before me, the undersigned authority, personally appeared __________________ (name), Complainant, who being

duly sworn according to law, deposes and says that he (or she) is authorized to make this affidavit, that he (or she)

believes that the facts set forth in the Complaint are true and correct.

________________________

Signature of Affiant

Sworn to and subscribed

before me this __________________ day

of __________________ (date).

Notary Public

My commission expires: __________________

FORM 105.05-11 Petition for Modification of Existing Support Order

(caption, including Docket No. and PACSES Case No.)

TO THE HONORABLE JUDGES OF THE SAID COURT:

1. The petition of ____________ respectfully represents that on ____________ (date), an order of court was

entered for the support of ____________. A true and correct copy of the order is attached to this petition as Exhibit

1A.1

2. Petitioner is entitled to ____________ (insert the relief sought, e.g., increase, decrease, modification,

termination, suspension, vacation) of this order because of the following material and substantial change(s) in

circumstances: ____________.

WHEREFORE, petitioner requests that the court modify the existing order for support.

________________________

(Attorney for Petitioner)

I verify that the statements made in this complaint are true and correct. I understand that false statements herein are

made subject to the penalties of 18 Pa. Cons. Stat. § 4904 relating to unsworn falsification to authorities.

Date:_______________

___

__________________

(Petitioner)

FORM 105.05-13 Supplemental Income Statement

1. This form is to be filled out by a person (check one) a. who operates a business or practices a profession, orb.

who is a member of a partnership or joint venture, orc. who is a shareholder in and is salaried by a closed corporation or

similar entity;

2. Attach to this statement a copy of the following documents relating to the partnership, joint venture, business

professional corporation or similar entity:a. the most recent Federal Income Tax Return, andb. the most recent Profit

and Loss Statement.3. Name of Business: __________________ Address of Business: __________________

Telephone:

4. Nature of Business (check one)a. partnership ______b. joint venture ______c. professional ______d. closed

corporation ______e. other ______

5. Name of accountant, controller or other person in charge of financial records:

Address: __________________

6. Annual Income from business: $ ____________a. how often is income received? __________________b. gross

income per pay period: __________________c. net income per pay period: __________________d. specified

deductions, if any: __________________

I, __________________, verify that the statements made in the attached Income and Expense Statement are true

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

subject to the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities.

________________________

Signature of (Plaintiff/Defendant)

FORM 105.05-14 Description Sheet of Person Wanted for Non-Support

(Montgomery County)

DESCRIPTION SHEET OF PERSON WANTED FOR NON-SUPPORT

DATE __________________ CASE NO. __________________

NAME OF DEFENDANT __________________

ALIAS (other names used) __________________

ADDRESS (including phone number) __________________

EMPLOYMENT __________________

NAME OF COMPANY __________________

ADDRESS OF COMPANY __________________

OCCUPATION __________________ SOC. SEC. # __________________

DESCRIPTION OF CAR __________________ LICENSE NO __________________

BIRTH DATE __________________ AGE ______ RACE __________________ COMPLEXION

__________________ HAIR COLOR __________________ HEIGHT ______ WEIGHT ______ lbs. EYE COLOR

__________________ BUILD (slim, medium, etc.) __________________ MUSTACHE AND/OR BEARD

__________________

ADDITIONAL PHYSICAL DESCRIPTION __________________

To assist in the location of the Defendant, please supply a photo with this Defendant information sheet. Has the

Defendant ever been convicted of a crime? ______

When? __________________

Where? __________________

Charges? __________________

Does the Defendant have a history of mental illness, or is he known to carry a gun or other weapon?

__________________

Has an abuse order been filed?____________

Can you think of anything else that will help us locate the Defendant, or can you supply the Sheriff's Office and

Domestic Relations Section with any additional information which will assist in locating the Defendant? ______ Please

write that information on back of this sheet.

Complainant's Name

__________________

Soc. Sec. #

__________________

Address

__________________

Employment

__________________

Home phone

__________________

Work phone

__________________

FORM 105.05-17 Entry of Appearance

(Caption)

TO THE PROTHONOTARY OF SAID COURT:

Please enter (my) (our) appearance for (Plaintiff/Defendant) in the above named __________________ (type of

domestic matter).

________________________

(Attorney signature and ID #)

Attorney for (Plaintiff/Defendant)

Date: __________________

FORM 105.05-18 STIPULATION AND AGREEMENT-ORDER FOR SUPPORT

(caption including docket no. and PACSES no.)

ORDER

AND NOW, this ____________ day of ____________, 20 ____________ the annexed Stipulation and Agreed

Order for Support and dated ____________ is hereby entered as an ORDER of this Court.

________________________

STIPULATION AND ORDER FOR SUPPORT

The parties hereby agree and stipulate to the following:

1. Plaintiff is ____________ (1Wife1) in the above-captioned support matter.

2. Defendant is ____________(1Husband1) in the above-captioned support matter.

3. The parties are Husband and Wife having been married on ____________ in ____________ County,

____________.

4. The parties have ____________ child(ren) born of the marriage:

5. On ____________, Wife filed a Complaint in Divorce which included, among other requests, a request for

support.

6. Husband shall pay the following expenses on behalf of Wife and the parties' children each month:

7. The parties agree that this Stipulation shall be entered as an Order by a court of competent jurisdiction.

_____________ __________________

_____

Witness Date

_____________

_____

__________________

Witness Date

FORM 105.05-19 STIPULATION AND AGREEMENT TO MODIFY SUPPORT ORDER

(Caption including docket no. and PACSES no.)

ORDER

AND NOW, this ____________ day of ____________, ____________ the annexed Stipulation and Agreed Order

for Modification of Support Order and dated ____________ is hereby entered as an ORDER of this Court.

________________________

STIPULATION AND AGREEMENT FOR MODIFICATION OF SUPPORT ORDER

The parties hereby agree and stipulate to the following:

1. Plaintiff is ____________ (1Wife1) in the above-captioned support matter.

2. Defendant is ____________ (1Husband1) in the above-captioned support matter.

3. The parties were previously husband and wife having been divorced by a decree of this court on ____________.

4. Petitioner and Respondent are the parents of ____________ minor child(ren), ____________, born

____________.

5. On ____________, The Honorable ____________ entered an Order of Support providing that Father pay

$____________ per week in child support.

6. Since the entry of the Support Order, the circumstances have changed in that ____________.

7. As a result of these changes, the parties agree that Father's child support payments should be ____________.

8. The parties agree that this Stipulation shall be entered as an Order by a court of competent jurisdiction.

By the Court,

_____________

_____

__________________

Witness Date

_____________

_____

__________________

Witness Date

FORM 105.05-24 EXCEPTIONS TO RECOMMENDATION OF CONFERENCE OFFICER/MASTER

(check one)

__________________

IN SUPPORT

__________________ IN EQUITABLE

DISTRIBUTION

EXCEPTION TO THE RECOMMENDATION dated the __________________ day of __________________, 20

__________________ A hearing de novo is requested in:

__________________ support

__________________ equitable distribution

__________________ __________________

Attorney for Plaintiff or Attorney for Defendant

Pro Se party, attorney ID or Pro Se party, attorney ID

__________________ __________________

Address Address

__________________ __________________

Phone No. () Phone No. ()

__________________

Signature

Field by:

__________________ Plaintiff

__________________ Defendant

(check one)

ORDER

AND NOW, on __________________ (date ), exceptions having been filed to the recommendation of

__________________ (conciliator) and a request for a hearing de novo, a hearing is fixed for __________________

(date) in courtroom No. ____________ of the Montgomery County Courthouse at ____________ (time).

By the Court,

________________________

cc:

Court Administrator

Domestic Relations

FORM 105.05-63 Statement of Arrearages for Entering Judgment

CASE NAME: ________________________ FILE NO: ____________ CASE NO.: ____________

DATE AND AMOUNT OF CURRENT ORDER: __________________

TOTAL ARREARS DUE ON CURRENT CERTIFICATE FROM THE COLLECTION OFFICE: $____________

* TOTAL ARREARS DUE THAT WERE NOT PREVIOUSLY REDUCED TO JUDGMENT: $____________

** DATE THIS STATEMENT WAS PREPARED: __________________

REQUESTED BY: __________________

PREPARED BY: __________________

* IT IS THE RESPONSIBILITY OF THE PARTY FILING THE PRAECIPE FOR JUDGMENT TO VERIFY

WHETHER ANY ARREARS WERE PREVIOUSLY REDUCED TO JUDGMENT BY REVIEWING THE DOCKET

ENTRIES AT THE ABOVE CASE NUMBER AND TO FILL OUT THE CERTIFICATION OF PARTY FILING

PRAECIPE ON THE LOWER PORTION OF THIS FORM.

** NOTE: THE STATUS OF EACH CASE VARIES FROM DAY TO DAY CAUSED BY ACCRUING

AMOUNTS AND/OR PAYMENTS MADE.

CERTIFICATION OF PARTY FILING FOR ENTRY OF JUDGMENT.

I HEREBY CERTIFY THAT I HAVE EXAMINED THE DOCKET ENTRIES FOR CASE NO: ____________

AND THAT THE AMOUNT OF SUPPORT ARREARS PREVIOUSLY REDUCED TO JUDGMENT TOTAL $.

________________________

Name

________________________

Date

FORM 105.05-64 Praecipe for Judgment

TO: __________________, PROTHONOTARY

Kindly enter judgment in favor of __________________ (Plaintiff/Defendant) and against __________________

(Debtor) in the amount of $ ____________.

By:________________________

________________________, Esquire

Attorney for (Plaintiff/Defendant)

FORM 105.05-65 Notice of Order, Decree or Judgment

TO: ( ) Plaintiff

( ) Defendant Garnishee

( ) Additional Defendant

You are hereby notified that the following order, decree, or judgment has been entered against you on.( ) Decree

Nisi in Equity.( ) Final Decree in Equity.

( ) Judgment

( ) Confession ( ) Verdict

( ) Default ( ) Non-Suit

( ) Non-Pros ( ) Arbitration

Award

( ) Judgment is in the amount of $ ____________, PLUS COSTS.

( ) District Justice Transcript of Judgment in CIVIL ACTION in the amount of $____________, PLUS COSTS.

( ) If not satisfied within sixty (60) days, your motor vehicle operator's license will be suspended by the

Pennsylvania Department of Transportation.

By:________________________

If you have any questions concerning the foreging, please contact:Name of (Attorney/Filing Party):

__________________

Address: __________________

Telephone Number: ____________

FORM 105.05-66 Praecipe for Writ of Execution

To the Prothonotary:

Please issue a Writ of Execution in the above-captioned matter,(1) directed to the Sheriff of County;(2) against

(Debtor) defendant and (Bank/Institution), Garnishee;(3) and Index this Writ against (Debtor) and (Bank/Institution),

Garnishee as lis pendens against real property of the Debtor/Defendant in the name of the garnishee as follows:

____________ (describe property)

(4) Amount due $____________

Interest $____________

(Costs to be added) $____________

By:________________________, Esquire

Attorney for ________________________ (Plaintiff/Defendant)

FORM 105.05-67 Writ of Execution Notice

This paper is a 1Writ of Execution.1 It has been issued because there is a judgment against you. It may cause your

property to be held or taken to pay the judgment. You may have legal rights to prevent your property from being taken.

A lawyer can advise you more specifically of these rights. If you wish to exercise your rights, you must act promptly.

The law provides that certain property cannot be taken and sold by the sheriff to satisfy your debts. SUCH

PROPERTY IS SAID TO BE EXEMPT. No matter what you may owe, there is a DEBTOR'S EXEMPTION

established by law. This means that no matter what happens, the sheriff must give you from the sale at least $300.00 in

cash or property. There are also other exemptions which may be applicable to you. Listed below is a summary of some

of the major exemptions. You may have other exemptions or other rights. If you have an exemption, you should do the

following promptly:

(1) Complete the claim form on the opposite side, and demand a prompt hearing.

(2) Deliver the form or mail it to the sheriff's office at the address noted.

You should come to court when and where you are told to appear ready to explain your exemption. IF YOU DO

NOT COME TO COURT AND PROVE YOUR EXEMPTION, YOU MAY LOSE SOME OF YOUR PROPERTY.

YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER

OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT

WHERE YOU CAN GET LEGAL HELP.

(Specify Local Lawyer Reference Service)

WRIT OF EXECUTION

To the Sheriff of ____________ County:

To satisfy the judgment, interest and costs against ____________ defendant,

(1) You are directed to levy upon the property of the defendant and to sell his interest therein;

(2) You are also directed to attach the property of the defendant not levied upon in the possession of

____________, as garnishee, ____________ (description of property), and to notify the garnishee that(a) An attachment

has been issued;(b) The garnishee is enjoined from paying any debt to or for the account of the defendant and from

delivering any property of the defendant or otherwise disposing thereof;(c) the attachment shall not include any funds in

an account of the defendant with a bank or other financial institution(i) in which funds are deposited electronically on a

recurring basis and are identified as being funds that upon deposit are exempt from execution, levy or attachment under

Pennsylvania or federal law; or(ii) that total $300 or less. If multiple accounts are attached, a total of $300 in all

accounts shall not be subject to levy and attachment as determined by the executing officer. The funds shall be set aside

pursuant to the defendant's general exemption provided in 42 Pa.C.S. § 8123.

(3) If property of the defendant not levied upon and subject to attachment is found in the possession of anyone other

than a named garnishee, you are directed to notify him that he has been added as a garnishee and is enjoined as above

stated.

Amount due $__________

Interest from

____________

$__________

Costs to be added $__________

__________________

(Name of Prothonotary/

Clerk)

Seal of the Court

By ____________

(deputy)

MAJOR EXEMPTIONS UNDER PENNSYLVANIA AND FEDERAL LAW

1.$300.00 exemption set by law.

2.Bibles, school books, sewing machines, uniforms, and equipment.

3.Tools of your trade, such as carpenter's tools.

4.Most wages and unemployment benefits.

5.Social Security benefits, certain retirement funds and accounts.

6.Certain veteran and armed forces benefits.

7.Certain insurance proceeds.

8.Such other exemptions as may be provided by law.

FORM 105.05-68 Claim for Exemption

TO THE SHERIFF:

I, __________________, the above-named defendant, claim exemption of property from levy of attachment:

(1) FROM MY PERSONAL PROPERTY IN MY POSSESSION THAT HAS BEEN LEVIED ON,(a) I desire that

my statutory $300.00 exemption be

($_________

___)

(1) set aside in kind: __________________

(specify property to be set aside in kind );

___________

(2) paid in cash following the sale of the

property levied on; or

(b) I claim the following exemption: __________________ (specify property and basis of exemption );

(2) FROM MY PROPERTY WHICH IS IN THE POSSESSION OF A THIRD PARTY, I CLAIM THE

FOLLOWING EXEMPTIONS:(a) My $300.00 statutory exemption:($____________) in cash;($____________) in

kind: __________________ (specify property );(b) Social Security benefits on deposit in the amount of

$____________;(c) Other: __________________ (specify amount and basis for exemption ).

I request a prompt court hearing to determine the exemption.

Notice of the hearing should be given me at the following:

__________________ __________________

(Address) (Telephone Number)

I verify that the statements made in this claim for exemption are true and correct. I understand that false statements

herein are made subject to the penalties of 18 Pa. Cons. Stat. § 4904 relating to unsworn falsification to authorities.

Date: ________________________

________________________

Defendant

THIS CLAIM TO BE FILED WITH: __________________ (Specify address and telephone number )

FORM 105.05-69 Affidavit

) ss:

Before me the undersigned authority, a Notary Public, in and for said County and Commonwealth personally

appeared, who being duly sworn according to law deposes and says that the facts and statements are true and correct to

the best of his (or her) knowledge, information and belief.

________________________

Sworn to and subscribed before me on this ____________ day of __________________.

________________________

FORM 105.05-70 Interrogatories to Garnishee

TO: __________________ (Bank/Institution )

__________________ (Address )

You are required to file Answers to the following Interrogatories within twenty (20) days after service upon you.

Failure to do so may result in judgment against you.

INTERROGATORIES TO GARNISHEE

1. At the time you were served or at any subsequent time, did you owe the (Debtor), Social Security Number

(hereinafter referred to as 1Debtor1) any money or were you liable to him (or her) on any negotiable or other written

instrument, or did he (or she) claim that you owed him (or her) any money or were liable to him (or her) for any

reason?

2. At the time you were served or at any subsequent time, was there in your possession, custody, or control or in the

joint possession, custody, or control of yourself and one or more other persons any property of any nature owned solely

or in part by the debtor?

3. At the time you were served or at any subsequent time, did you hold legal title to any property of any nature

owned solely or in part by the debtor or in which debtor held or claimed any interest?

4. At the time you were served or at any subsequent time, did you hold as fiduciary any property in which the

debtor had an interest?

5. At any time before or after you were served, did the debtor transfer or deliver any property to you or to any

person or place pursuant to your direction or consent and, if so, what was the consideration therefor?

6. At any time after you were served did you pay, transfer, or deliver any money or property to the debtor or to any

person or place pursuant to his (or her) direction or otherwise discharge any claim of the debtor against you?

7. If you are a bank or other financial institution, at the time you were served or at any subsequent time did the

defendant have funds on deposit in an account in which funds are deposited electronically on a recurring basis and

which are identified as being funds that upon deposit are exempt from execution, levy or attachment under Pennsylvania

or federal law? If so, identify each account and state the reason for the exemption, the amount being withheld under

each exemption and the entity electronically depositing those funds on a recurring basis.

8. If you are a bank or other financial institution, at the time you were served or at any subsequent time did the

defendant have funds on deposit in an account in which the funds on deposit, not including any otherwise exempt funds,

did not exceed the amount of the general monetary exemption under 42 Pa.C.S. § 8123? If so, identify each account.

By:________________________, Esquire

Attorney for (Plaintiff/Defendant)

FORM 105.05-71 Praecipe for Judgment Against Garnishee (Bank/Institution)

TO THE PROTHONOTARY:

Kindly enter judgment against the Garnishee, (Bank/Institution) in the amount of $____________.

By:________________________, Esquire

Attorney for (Plaintiff/Defendant)

FORM 105.05-72 Certificate of Service

I hereby certify that the within Praecipe for Judgment against Garnishee was served upon the person in the manner

indicated below on this ____________ day of __________________.

Service by First-Class Mail, Postage Prepaid:

__________________ (Bank/Institution )

__________________ (Address )

By:________________________, Esquire

Attorney for (Plaintiff/Defendant)

FORM 105.05-73 Praecipe to Settle, Discontinue, and Satisfy

TO THE PROTHONOTARY:

To settle, discontinue, and satisfy the above-captioned case as to garnishee only.

Others: __________________.

________________________

Attorney for Plaintiff

________________________

Attorney for Defendant

I hereby certify that the foregoing is a true and correct statement of the above-captioned case.

This statement is made subject to the penalties of 18 Pa. Cons. Stat. § 4904 relating to unsworn falsifications to

authorities.

By:________________________

FORM 106.03-2 Acknowledgment of Paternity and Waiver of Trial

Family Court Division (or) Domestic Relations Section

I, ____________, do hereby acknowledge that I am the father of the following child(ren) born to ____________

(natural mother) of ____________ (her address):

Child's Name Date of Birth Place of Birth

_____________

_____

______________

____

______________

____

_____________

_____

______________

____

______________

____

_____________

_____

______________

____

______________

____

I have been advised of and do hereby waive my rights to (1) a trial on the issue of paternity which must be proven

by a preponderance of the evidence, (2) an attorney to represent me on the issue of paternity both at the trial thereon and

in this action for support and (3) appointment of an attorney to represent me on the issue of paternity only; this attorney

would be provided if I could establish that I qualify for such representation due to indigence.

Witness:

__________________

Domestic Relations Officer

________________________

Defendant

________________________

Attorney for Defendant

I verify that the statements made in this acknowledgment and waiver are true and correct. I understand that false

statements herein are made subject to the penalties of 18 Pa. Cons. Stat. Ann. § 4904, relating to unsworn falsification

to authorities.

Date: ____________

________________________

Defendant

ORDER

AND NOW, this ____________ day of ____________, ______ (year), upon recommendation of the Domestic

Relations Officer named above, the acknowledgment of paternity and waiver of trial are accepted.

By the Court:

________________________

FORM 106.03-3 Order for Blood Test-Paternity

AND NOW, this ____________ day of ____________, ______ (year), upon denial of paternity by the defendant,

____________, and upon petition by the defendant through his counsel, ____________, Esquire, the court makes the

following order:

The Complainant, ____________, the minor child or children, whose paternity is in question, ____________, and

the defendant, ____________, are hereby ordered to submit to genetic testing.

The genetic testing is to take place on the ____________ day of ____________, ________________________

(year), at ____________ o'clock ____________.M. at ________________________ (address).

The cost of said testing shall be paid by the defendant.

The Domestic Relations Section of this Court, will be responsible for contacting the blood laboratory, arranging the

date and time for testing and notifying all parties, for the collection and disbursement of the fees in regard thereto and

for forwarding the findings of the laboratory to all parties of the case and to the Court sitting.

By the Court:

________________________

FORM 106.03-4 ORDER TO APPEAR FOR GENETIC TESTING

The Defendant has not acknowledged paternity of the following child(ren):

CHILD'S NAME DATE OF

BIRTH

PLACE OF BIRTH

_____________

_____

_____________

_____

born to ________________________ (name of biological mother).

The parties and the child(ren) are ordered to appear for genetic testing on ____________ (date), at ____________

(time), at ________________________ (address), and to stay until excused.

If the defendant fails to appear for genetic testing as ordered, the court will enter an order finding that the defendant

is the father of the child. If the plaintiff fails to appear or fails to make the child(ren) available for testing as ordered, the

court may enter an order dismissing the paternity action without prejudice.

BY THE COURT,

________________________

FORM 106.03-5 Petition for Blood Test

TO THE HONORABLE, THE JUDGES OF SAID COURT:

The Petition of __________________ (name) respectfully represents as follows:

1. This petition is brought under the Uniform Act on Blood Tests to Determine Paternity.

2. Petitioner/Plaintiff, __________________ (name), resides at __________________ (address).

3. Respondent/Defendant __________________ (name), is an individual residing at __________________

(address).

4. The Petitioner/Plaintiff has named Respondent as the father of her child __________________ (name of child),

born __________________, (date of birth), in her complaint for support filed __________________, (date of filing).

5. The Respondent/Defendant denies paternity of the said minor child.

6. The Petitioner/Plaintiff desires to support her claim of paternity and therefore wishes to present the results of

genetic testing taken of Petitioner, the subject child, and Respondent.

7. The Petitioner/Plaintiff is receiving public assistance.

WHEREFORE, Petitioner respectfully requests this Honorable Court to enter an Order directing that Petitioner,

Respondent, and the subject child submit to genetic tests. The costs are to be paid by the County of ____________,

Pennsylvania, with reimbursement to be paid by Defendant if a finding of paternity is ultimately made against the

Defendant.

By: ________________________

Attorney for Petitioner/Plaintiff

FORM 106.03-6 Order

AND NOW, this __________________, (date), upon consideration of the within Petition and pursuant to the

Uniform Act on Blood Tests to Determine Paternity, 23 Pa. Cons. Stat. Ann. § 5104. IT IS HEREBY ORDERED

THAT:Defendant

Plaintiff

Minor Child of Plaintiff

appear at the __________________ Health Department, __________________ (address), __________________,

Pennsylvania, for genetic tests on __________________, (testing date) at ____________ ______.m. to be performed by

__________________ Laboratories, Inc., the results of which may be offered into evidence. It is further ORDERED

that the costs of said tests shall be borne by County of Chester, Pennsylvania, with reimbursement to the County by the

Defendant, if a finding of paternity is ultimately made against the Defendant.

By the Court,

________________________,