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

       (a)    The Notice of Hearing and Order required by [Rule]Pa.R.C.P. No. 1901.3
shall be substantially in the following form:

                                        (Caption)

                          NOTICE OF HEARING AND ORDER

         YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set
forth in the following papers, you must appear at the hearing scheduled herein. If you
fail to do so, the case may proceed against you and a FINAL order may be entered
against you granting the relief requested in the petition. In particular, you may be
evicted from your residence, [be] prohibited from possessing any firearm, other
weapon, ammunition, or any firearm license, and lose other important rights, including
custody of your children. [Any]A 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) and Child Protective Services Law proceedings under Chapter 63
(related to juvenile matters).

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

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

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

      NOTICE: Even if this order does not direct you to relinquish firearms, you
may be subject to federal firearms prohibitions and federal criminal penalties
under 18 U.S.C. § 922(g)(8) or state firearms prohibitions and state criminal
penalties under 18 Pa.C.S. § 6105.

[YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. ]YOU HAVE
THE RIGHT TO HAVE A LAWYER REPRESENT YOU AT THE HEARING[.],
HOWEVER, THE COURT WILL NOT[, HOWEVER,] APPOINT A LAWYER FOR YOU.
YOU HAVE THE RIGHT TO PRESENT EVIDENCE AT THE HEARING, INCLUDING
SUBPOENAING WITNESSES TO TESTIFY ON YOUR BEHALF.

YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. 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, Zip Code]
                                       [Insert Phone]


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




                                              2
PETITION FOR PROTECTION                                                            IN THE COURT OF COMMON
      FROM ABUSE                                                                   PLEAS OF        COUNTY, PENNSYLVANIA
                                                                                   NO.
1.           PLAINTIFF




First                                          Middle                   Last                                             Plaintiff’s DOB
Plaintiff's Address:
     Plaintiff's address is confidential or   Plaintiff's address is:
                                       V.


2.           DEFENDANT




First                                          Middle                              Last                             Suffix
Defendant’s Address:                                                                                       DEFENDANT IDENTIFIERS
                                                                                          DOB                       HEIGHT
                                                                                          SEX                       WEIGHT
                                                                                          RACE                      EYES
                                                                                          HAIR
                                                                                          SSN
CAUTION:
                                                                                          DRIVERS
            Weapon Involved                                                              LICENSE #
            Weapon Present on the Property                                               EXP DATE                        STATE
            Weapon Requested Relinquished
Defendant's Place of employment is:
            Check here if you have reason to believe that Defendant is a licensed firearms dealer, [is ]employed by a licensed firearms dealer or
manufacturer; [is ]employed as a writer, researcher, or technician in the firearms or hunting industry, or is required to carry a firearm as a condition of
employment.




3.           I am filing this Petition on behalf of:     Myself         [and/]or          Another Person
If you checked "myself", please answer all questions referring to yourself as "Plaintiff". If you ONLY checked "another person", please answer all
questions referring to that person as the "Plaintiff", and provide your name and address here, as filer, unless confidential.
Filer's Name:




First                              Middle                               Last                                        Suffix
            Filer’s Address is Confidential or        Filer’s address is:
If you checked "Another Person", indicate your relationship with Plaintiff:
            parent of minor Plaintiff(s)
            applicant for appointment as guardian ad litem of minor Plaintiff(s)
            adult household member with minor Plaintiff(s)
            court appointed guardian of incompetent Plaintiff(s)


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




                                                                                      3
5.      Indicate the relationship between Plaintiff and Defendant[.]:

CHECK ALL THAT APPLY:
    spouse or former spouse of Defendant
    parent of a child with Defendant
    current or former sexual or intimate partner with Defendant
    child of Plaintiff
    child of Defendant
    family member related by blood (consanguinity) to Defendant
    family member related by marriage or affinity to Defendant
    sibling (person who shares parenthood) of Defendant

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

6.      Have Plaintiff and Defendant been involved in any of the following court actions?
     Divorce     Custody       Support      Protection from Abuse

        If you checked any of the above, briefly indicate when and where the case was
filed and the court number, if known:


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

        If you answered Yes, is Defendant currently on probation?

      Has Defendant been determined to be a perpetrator in a founded or
indicated report under the Child Protective Services Law, 23 Pa.C.S. §§ 6301 -
6386?

     If you answered Yes, what county’s court or child protective services
agency issued the founded or indicated report?

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

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




9.      If Plaintiff and Defendant are parents of any minor child/ren together, is there an



                                              4
existing court order regarding their custody?

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


       If you answered "yes", in what county and state was the order issued?


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

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

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




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

Name                        Address                                     Basis of Claim




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

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




11.    The facts of the most recent incident of abuse are as follows:
Approximate Date:
Approximate Time:
Place:


                                              5
Describe in detail what happened, including any physical or sexual abuse, threats,
injury, incidents of stalking, medical treatment sought, [and/]or calls to law enforcement.
(attach additional sheets of paper if necessary):




12.     If [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):




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




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

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

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

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


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


                                              6
     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 THE 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]harassing, stalking, threatening, or attempting or threatening to
use physical force against Plaintiff or the minor child/ren in any place where Plaintiff
[and/]or the child/ren may be found.

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

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

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


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

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


                                              7
Name                         Address (optional)                 Relationship to Plaintiff




       G.      Order Defendant to temporarily relinquish [some or all of ]the firearms,
other weapons, [and/]or ammunition listed on Attachment A to Petition, under
Defendant’s control, or in Defendant’s possession, or[ and] any firearm license to
the sheriff [of this county and/or prohibit]or the appropriate law enforcement
agency.

        H.     Prohibit Defendant from [transferring,] acquiring[,] or possessing [some
or all] firearms for the duration of the order.

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

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

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

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




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

        [N]O. Order the police, sheriff, or other law enforcement agency to serve [the]
Defendant with a copy of this petition, any order issued, and the order for hearing.
Plaintiff will inform the designated authority of any addresses, other than [the]
Defendant's residence, where Defendant can be served.

       P.     Direct the Pennsylvania State Police, the municipal police, or the
sheriff to accompany Plaintiff to his or her residence to retrieve personal
belongings or accompany Plaintiff while the petition or order is served on


                                              8
Defendant, if Plaintiff has reason to believe his or her safety is at risk.

                                     VERIFICATION

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


                                                        Signature

                                                        Date




                                             9
                                        (Caption)

                          ATTACHMENT A TO PETITION
                      FIREARMS, OTHER WEAPONS, [AND]OR
                            AMMUNITION INVENTORY

 I,                         , Plaintiff in this Protection from Abuse Action, hereby

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

Firearm/Other Weapon/Ammunition                                       Location

1.
2.
3.
4.
5.

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

Firearm/Other Weapon/Ammunition                                       Location

1.
2.
3.
4.
5.

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

Firearm/Other Weapon/Ammunition                                       Location

1.
2.
3.
4.
5.


                                           10
□    All firearms, other weapons, [and]or ammunition owned or possessed by
Defendant.
If more space is needed, more sheets may be attached to this document.

Name:

Date:


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


       Note: See Pa.R.C.P. No. 1930.1(b). This rule may require attorneys or
unrepresented parties to file confidential documents and documents containing
confidential information that are subject to the Case Records Public Access Policy of
the Unified Judicial System of Pennsylvania.


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




                                           11
           TEMPORARY PROTECTION                                                    IN THE COURT OF COMMON PLEAS OF
             FROM ABUSE ORDER                                                      _________________COUNTY, PENNSYLVANIA
              Amended Order             Continued Order                            NO.

PLAINTIFF


First                                      Middle                         Last                                Plaintiff’s DOB
Name(s) of all protected persons, including minor child/ren and DOB:




                     V.


DEFENDANT


First                                      Middle                         Last                                       Suffix
Defendant’s Address:                                                                                      DEFENDANT IDENTIFIERS
                                                                                      DOB                          HEIGHT
                                                                                      SEX                          WEIGHT
                                                                                      RACE                         EYES
                                                                                      HAIR
                                                                                      SSN
CAUTION:                                                                              DRIVERS
       Weapon Involved                                                               LICENSE #
                                                                                      EXP DATE                             STATE
       Weapon Present on the Property
       Weapon Ordered Relinquished


The Court Hereby Finds: That it has jurisdiction over the parties and subject matter, and [the] Defendant will be provided with reasonable notice and
opportunity to be heard.
The Court Hereby Orders:
       Defendant shall not abuse, harass, stalk, [or] threaten, or attempt or threaten to use physical force against any of the above persons in any
place where they might be found.
       Except for such contact with the minor child/ren as may be permitted under [paragraph]Paragraph 5 of this order, Defendant shall not contact
Plaintiff, or any other person protected under this order, by telephone or by any other means, including through third persons.
          Additional findings of this order are set forth below.
Order Effective Date                                                       Order Expiration Date

                                                               NOTICE TO [THE] DEFENDANT
           Defendant is hereby notified that [violation of]failure to obey this order may result in arrest as set forth in 23 Pa.C.S. § 6113 and that
violation of the order may result in a charge of [for] indirect criminal contempt[, which is punishable by a fine of up to $1,000 and/or up to six
months in jail.]as set forth in 23 Pa.C.S.[A.] § 6114. Consent of Plaintiff to Defendant's return to the residence shall not invalidate this order, which
can only be changed or modified through the filing of appropriate court papers for that purpose. 23 Pa.C.S. [A.] § 6108 (g). If Defendant is required to
relinquish any firearms, other weapons, [or] ammunition, or any firearm license, those items must be relinquished to the sheriff or the appropriate law
enforcement agency within 24 hours of the service of this order. As an alternative, Defendant may relinquish any firearm, other weapon, or ammunition
listed herein to a third party provided Defendant and the third party first comply with all requirements to obtain a safekeeping permit. If, due to their
current location, firearms, other weapons, or ammunition cannot reasonably be retrieved within the time for relinquishment, Defendant shall provide an
affidavit to the sheriff or the appropriate law enforcement agency listing the firearms, other weapons, or ammunition and their current location no later
than 24 hours after the service of this order. Defendant is further notified that violation of this order may subject him/her to state charges and penalties
under the Pennsylvania Crimes Code under 18 Pa.C.S. § 6105 and to federal criminal charges and penalties under 18 U.S.C. § 922(g)(8) and the
Violence Against Women Act, 18 U.S.C. §§ 2261-2262.


                                                                              12
       AND NOW, this        day of _______, 20__, upon consideration of the attached
Petition for Protection From Abuse, the court hereby enters the following Temporary
Order:

      Plaintiff's request for a Temporary Protection Order is denied.
      Plaintiff's request for a Temporary Protection Order is granted.

     1.     Defendant shall not abuse, harass, stalk, [or] threaten, or attempt or
threaten to use physical force against any of the above persons in any place where
they might be found.

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

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


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

      5.     CUSTODY.

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


(county court)                                                           (docket number)

             THIS ORDER SHALL NOT SUPERSEDE THE CURRENT CUSTODY
              ORDER.

             THIS ORDER SUPERSEDES ANY PRIOR ORDER RELATING TO


                                              13
              CHILD CUSTODY.

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




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




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

   6.    FIREARMS, OTHER WEAPONS, [AND]OR AMMUNITION
RESTRICTIONS

Check all that apply.

             Defendant is prohibited from possessing[, transferring] or acquiring any
              firearms for the duration of this order.
             Defendant shall relinquish to the sheriff or the appropriate law
              enforcement agency the following firearm[s] licenses owned or
              possessed by Defendant.




             Defendant is directed to relinquish to the sheriff or the appropriate law
              enforcement agency any firearm, other weapon, or ammunition listed in
              Attachment A to Temporary Order, which is incorporated herein by
              reference, under Defendant’s control or in Defendant’s possession.

        Defendant may relinquish any firearms, other weapons, or ammunition to the
sheriff or the appropriate law enforcement agency. As an alternative, Defendant may
relinquish firearms, other weapons, [and]or 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 firearm license ordered to be relinquished no later than 24 hours after service of this
order. If, due to their current location, firearms, other weapons, or ammunition cannot
reasonably be retrieved within the time for relinquishment, Defendant shall provide to
the sheriff or the appropriate law enforcement agency an affidavit listing the firearms,


                                             14
other weapons, or ammunition and their current location no later than 24 hours after
service of this order. Failure to timely relinquish any firearm, other weapon, ammunition,
or any firearm license shall result in a violation of this order and may result in criminal
conviction under the Uniform Firearms Act, 18 Pa.C.S.[A.] § 6105.

      7.     The following additional relief is granted:

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

       Name                   Address (optional)               Relationship to Plaintiff




             Other relief:




      8.  The Pennsylvania State Police, the municipal police, or the sheriff
shall accompany Plaintiff to his or her residence to retrieve personal belongings
or accompany Plaintiff while the petition or order is served on Defendant.

     [8]9. A certified copy of this order shall be provided to the sheriff or police
department where Plaintiff resides and any other agency specified hereafter: [insert
name of agency]

   [9]10. THIS ORDER SUPERSEDES ANY PRIOR PROTECTION FROM ABUSE
ORDER OBTAINED BY THE SAME PLAINTIFF AGAINST THE SAME DEFENDANT.

     [10]11.    THIS ORDER APPLIES IMMEDIATELY TO DEFENDANT AND
SHALL REMAIN IN EFFECT UNTIL [insert expiration date] OR UNTIL OTHERWISE
MODIFIED OR TERMINATED BY THIS COURT AFTER NOTICE AND HEARING.

                              NOTICE TO [THE] DEFENDANT

        Defendant is hereby notified that [violation of]failure to obey this order may
result in arrest as set forth in 23 Pa.C.S. § 6113 and that violation of the order
may result in a charge of[for] indirect criminal contempt[, which is punishable by
a fine of up to $1,000 and/or up to six months in jail.]as set forth in 23
Pa.C.S.[A.] § 6114. Consent of Plaintiff to Defendant's return to the residence shall
not invalidate this order, which can only be changed or modified through the filing of


                                             15
appropriate court papers for that purpose. 23 Pa.C.S.[A.] § 6108(g). If Defendant is
required to relinquish any firearms, other weapons, [or] ammunition, or any firearm
license, those items must be relinquished to the sheriff or the appropriate law
enforcement agency within 24 hours of the service of this order. As an alternative,
Defendant may relinquish any firearm, other weapon, or ammunition listed herein to a
third party provided Defendant and the third party first comply with all requirements to
obtain a safekeeping permit. If, due to their current location, firearms, other weapons,
or ammunition cannot reasonably be retrieved within the time for relinquishment,
Defendant shall provide an affidavit to the sheriff or the appropriate law
enforcement agency listing the firearms, other weapons, or ammunition and their
current location no later than 24 hours after the service of this order. Defendant is
further notified that violation of this order may subject him/her to state charges and
penalties under the Pennsylvania Crimes Code under 18 Pa.C.S. § 6105 and to
federal criminal charges and penalties under 18 U.S.C. § 922(g)(8) and the
Violence Against Women Act, 18 U.S.C. §§ 2261-2262.

       NOTICE TO SHERIFF, POLICE AND LAW ENFORCEMENT OFFICIALS

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

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

BY THE COURT:


                           Judge

                           Date


                                            16
                                        (Caption)

                      ATTACHMENT A TO TEMPORARY ORDER
                      FIREARMS, OTHER WEAPONS, [AND]OR
                            AMMUNITION INVENTORY

    It is hereby ordered that Defendant relinquish the following firearms, other
weapons, [and]or ammunition to the sheriff or the appropriate law enforcement
agency:


Firearm/Other Weapon/Ammunition                                 Location
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

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

BY THE COURT

                                           Judge

                                           Date:


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

                                           ***

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




                                            17
           FINAL PROTECTION FROM                                                 IN THE COURT OF COMMON PLEAS OF
                 ABUSE ORDER                                                                       COUNTY, PENNSYLVANIA
              Extended Order            Amended Order                            NO.

PLAINTIFF



First                             Middle                                              Last                                   Plaintiff’s DOB
Name(s) of all protected persons, including minor child/ren and DOB:




                    V.

DEFENDANT



First                                      Middle                                  Last                                      Suffix
Defendant’s Address:                                                                                    DEFENDANT IDENTIFIERS
                                                                                    DOB                            HEIGHT
                                                                                    SEX                            WEIGHT
                                                                                    RACE                           EYES
                                                                                    HAIR
                                                                                    SSN
CAUTION:                                                                            DRIVERS
                                                                                    LICENSE #
         Weapon Involved
                                                                                    EXP DATE                            STATE
         Weapon Present on the Property
         Weapon Ordered Relinquished


The Court Hereby Finds: That it has jurisdiction over the parties and subject matter, and [the] Defendant has been provided with reasonable notice
and opportunity to be heard.
The Court Hereby Orders:
         Defendant shall not abuse, harass, stalk, [or] threaten, or attempt or threaten to use physical force against any of the above persons in
any place where they might be found.
         Except as provided in [paragraph]Paragraph 5 of this order, Defendant shall not contact Plaintiff, or any other person protected under this
order, by telephone or by any other means, including through third persons.
         Additional findings of this order are set forth below.
Order Effective Date                                                     Order Expiration Date


                                                              NOTICE TO [THE] DEFENDANT
          [Violation of this order may result in your arrest on the charge of indirect criminal contempt which is punishable by a fine of up to
$1,000 and/or a jail sentence of up to six months. 23 Pa.C.S.A. § 6114]Defendant is hereby notified that failure to obey this order may result in
arrest as set forth in 23 Pa.C.S. § 6113 and that violation of the order may result in a charge of indirect criminal contempt as set forth in 23
Pa.C.S. § 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]or ammunition
to the sheriff or the appropriate law enforcement agency. Plaintiff's consent to contact by Defendant shall not invalidate this order which can only be
modified by further order of court. 23 Pa.C.S.[A.] § 6108(g).
          This order is enforceable in all fifty (50) States, the District of Columbia, Tribal Lands, U.S. Territories, and the Commonwealth of Puerto Rico
under the Violence Against Women Act, 18 U.S.C. § 2265. If you travel outside of the state and intentionally violate this order, you may be subject to
federal criminal proceedings under that act. 18 U.S.C. §§ 2261-2262. If you possess a firearm or any ammunition while this order is in effect, you may be
charged with a federal criminal offense even if this Pennsylvania order does not expressly prohibit you from possessing firearms or ammunition[.]
under 18 U.S.C. § 922(g)(8)[.] or state criminal offenses and state criminal penalties under 18 Pa.C.S. § 6105.



                                                                            18
CHECK ALL THAT APPLY:

Plaintiff or Protected Person(s) is/are:

       spouse or former spouse of Defendant
       parent of a child with Defendant
       current or former sexual or intimate partner with Defendant
       child of Plaintiff
       child of Defendant
       family member related by blood (consanguinity) to Defendant
       family member related by marriage or affinity to Defendant
       sibling (person who shares parenthood) of Defendant

       Defendant was served in accordance with Pa.R.C.P. No. 1930.4 and provided
notice of the time, date, and location of the hearing scheduled in this matter.

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

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

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

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

OR

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

      1.    Defendant shall not abuse, stalk, harass, threaten, or attempt or threaten
to use physical force [that would reasonably be expected to cause bodily injury


                                              19
to]against Plaintiff or any other protected person in any place where they might be
found.

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

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


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




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

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

Check all that apply.

   STATE TO WHOM PRIMARY PHYSICAL CUSTODY IS AWARDED; STATE
TERMS OF PARTIAL CUSTODY, IF ANY.




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

(county court)                                                 (docket number)


                                            20
     A custody petition is pending.

     A hearing is scheduled for[:]


(Date, time and location)

     THIS ORDER SHALL NOT SUPERSEDE THE CURRENT CUSTODY ORDER.

   THIS ORDER SUPERSEDES ANY PRIOR ORDER RELATING TO CHILD
CUSTODY.

The custody provisions of [paragraph]Paragraph 5 of this order are temporary. Either
party may initiate custody proceedings pursuant to the custody statute at 23 Pa.C.S. §§
5321[ et seq] — 5340. Any valid custody order entered after the final Protection From
Abuse order supersedes the custody provisions of this order.

   6.    FIREARMS, OTHER WEAPONS, [AND]OR AMMUNITION
RESTRICTIONS

Check all that apply:

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

    Defendant shall relinquish to the sheriff or the appropriate law enforcement
agency the following firearm[s] licenses owned or possessed by Defendant:




      Defendant is directed to relinquish to the sheriff or the appropriate law
enforcement agency any firearm, other weapon, or ammunition listed in Attachment A
to Final Order, which is incorporated herein by reference.

        Defendant may relinquish any firearms, other weapons, or ammunition to the
sheriff or the appropriate law enforcement agency. As an alternative, Defendant
may either relinquish firearms, other weapons, [and]or ammunition to a third party
provided Defendant and the third party first comply with all the requirements to obtain a
safekeeping permit, or relinquish firearms, other weapons, [and]or ammunition to a
licensed firearms dealer for consignment sale, lawful transfer, or safekeeping pursuant
to 23 Pa.C.S.[A.] § 6108.2(e). Defendant must relinquish any firearm, other weapon,
ammunition, or firearm[s] license ordered to be relinquished no later than 24 hours after


                                           21
service of this order. Failure to timely relinquish any firearm, other weapon,
ammunition, or any firearm license ordered to be relinquished shall result in a violation
of this order and may result in criminal conviction under the Uniform Firearms Act, 18
Pa.C.S.[A.] § 6105.

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

      8.  The Pennsylvania State Police, the municipal police, or the sheriff
shall accompany Plaintiff to his or her residence to retrieve personal belongings.

□      9.     The following additional relief is granted as authorized by § 6108 of the
Act:

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

Name                        Address (optional)                 Relationship to Plaintiff




      Other relief:




       [9]10. Defendant is directed to pay temporary support for: [INSERT THE NAMES
OF THE PERSONS FOR WHOM SUPPORT IS TO BE PAID] as follows: [INSERT
AMOUNT, FREQUENCY AND OTHER TERMS AND CONDITIONS OF THE
SUPPORT ORDER]. This order for support shall remain in effect until a final support
order is entered by this court. However, this order shall lapse automatically if Plaintiff
does not file a complaint for support with the Domestic Relations Section of the court
within two weeks of the date of this order. The amount of this temporary order does not
necessarily reflect Defendant’s correct support obligation, which shall be determined in
accordance with the guidelines at the support hearing. Any adjustments in the final
amount of support shall be credited, retroactive to this date, to the appropriate party.



                                            22
[10]11.       □      (a)    The costs of this action are imposed on Defendant.

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

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

    [11]12.       Defendant shall pay $         to Plaintiff by (insert date) as
compensation for Plaintiff's out-of-pocket losses, which are as follows:

              An installment schedule is ordered as follows:


OR

□        Plaintiff is granted leave to present a petition, with appropriate notice to
Defendant, to [INSERT THE NAME OF THE JUDGE OR COURT TO WHICH THE
PETITION SHOULD BE PRESENTED] requesting recovery of out-of-pocket losses.
The petition shall include an exhibit itemizing all claimed 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]13.   THIS ORDER [SUPERCEDES]SUPERSEDES ANY PRIOR
PROTECTION FROM ABUSE ORDER OBTAINED BY THE SAME PLAINTIFF
AGAINST THE SAME DEFENDANT.

       [13]14.       All provisions of this order shall expire:

CHECK ONE

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

      in three years, on [INSERT EXPIRATION DATE]

                             NOTICE TO [THE] 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


                                             23
sentence of up to six months. 23 Pa.C.S.A. § 6114]Defendant is hereby notified
that failure to obey this order may result in arrest as set forth in 23 Pa.C.S. § 6113
and that violation of the order may result in a charge of indirect criminal contempt
as set forth in 23 Pa.C.S. § 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 or the
appropriate law enforcement agency. Plaintiff's consent to contact by Defendant shall
not invalidate this order, which can only be modified by further order of court. 23
Pa.C.S.[A.] § 6108(g).

        This order is enforceable in all fifty (50) States, the District of Columbia, Tribal
Lands, U.S. Territories, and the Commonwealth of Puerto Rico under the Violence
Against Women Act, 18 U.S.C. § 2265. If you travel outside of the state and
intentionally violate this order, you may be subject to federal criminal proceedings under
that act. 18 U.S.C. §§ 2261-2262. If you possess a firearm or any ammunition while this
order is in effect, you may be charged with a federal criminal offense even if this
Pennsylvania order does not expressly prohibit you from possessing firearms or
ammunition[.] under 18 U.S.C. § 922(g)(8)[.] or state criminal offenses and state
criminal penalties under 18 Pa.C.S. § 6105.

      NOTICE TO SHERIFF, POLICE, AND LAW ENFORCEMENT OFFICIALS

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

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

       When Defendant is placed under arrest for violation of the order, Defendant shall
be taken to the appropriate authority or authorities before whom Defendant is to be
arraigned. A "Complaint for Indirect Criminal Contempt" shall then be completed and
signed by the police officer, sheriff, OR Plaintiff. Plaintiff's presence and signature are


                                             24
not required to file the complaint.

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

BY THE COURT:


                                      Judge

                                      Date

[If]This order was entered pursuant to the consent of [plaintiff and
defendant]Plaintiff and Defendant:


Plaintiff’s Signature                              Defendant’s Signature




                                              25
                                       (Caption)

                        ATTACHMENT A TO FINAL ORDER
                        FIREARMS, OTHER WEAPONS AND
                            AMMUNITION INVENTORY

    It is hereby ordered that Defendant relinquish the following firearms, other
weapons, and ammunition to the sheriff or the appropriate law enforcement agency:


Firearm/Other Weapon/Ammunition                               Location
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

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

BY THE COURT

                                         Judge

                                         Date:


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

                                          ***




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