FORM 5.15 Stipulation for Custody Supervision

IN THE COURT OF COMMON PLEAS OF

__________________ COUNTY, PENNSYLVANIA

CIVIL ACTION-LAW

PLAINTIFF

vs No. CI -

DEFENDANT

STIPULATION FOR CUSTODY SUPERVISION

AND NOW, Plaintiff __________________ (``Father''), his stepmother ________________

(``Supervisor''), and Defendant stipulate and agree as follows:

1. On __________________, the Honorable __________________ ordered that Plaintiff's

visitation with Child was to be supervised.

2. The parties have agreed that __________________ will serve as the supervisor during

Plaintiff's visitation periods with Child.

3. __________________ shall be physically present with Child at all times when Plaintiff

has visitation with Child.

4. __________________ shall be responsible for ensuring that Child is not placed in

potentially dangerous situations.

__________________

Supervisor

__________________

Plaintiff

__________________

Defendant

Date: _________

APPROVED BY THE COURT:

Date: ________ __________________

J.