Rule 1959. Forms for Use in Protection of Victims of Sexual Violence or
Intimidation Actions. Notice and Hearing. Petition. Temporary Protection Order.
Final Protection Order.


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      (b)     The petition in an action filed pursuant to the Act shall be identical in
content to the following form:

                                         (Caption)


                     PETITION FOR PROTECTION OF VICTIMS OF
                                SEXUAL VIOLENCE
                                SEXUAL VIOLENCE AGAINST A MINOR CHILD
                                INTIMIDATION

1.   Plaintiff:
_____________________________________________________________________
     First      Middle          Last Name

Plaintiff’s Address: ______________________________________________________

   Plaintiff’s address is confidential pursuant to 42 Pa.C.S. § 62A11.

Plaintiff’s Date of Birth: _______________________________________________

I am filing this petition on behalf of myself 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
“Plaintiff,” and provide your name and address below.

Name: __________________________________________________________

Address: _________________________________________________________

If you checked “another person,” indicate your relationship to the plaintiff:

_____________________________________________________________________



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2.    Defendant:

________________________________                             DEFENDANT IDENTIFIERS
                                                DOB                   HEIGHT
First Middle    Last Name                       SEX                   WEIGHT
                                                RACE                  EYES
Defendant’s Address:                            HAIR
                                                SSN
________________________________                DRIVERS
________________________________                LICENSE #
                                                EXP DATE                STATE


3.    Name(s) of other designated person(s) under 42 Pa.C.S. § 62A07(b)(1):

____________________________________________________________________

4.      Is there a relationship between Plaintiff and Defendant? ________. If yes, what
is the relationship?
_____________________________________________________________________

5.     Have Plaintiff and Defendant been involved in any other legal proceedings? If
so, state when and where the case was filed and the court docket number, if known:
_____________________________________________________________________
_____________________________________________________________________

6. Has Defendant been involved in any criminal proceedings?
______________________________________________________________________

If you answered Yes, is Defendant currently on probation or parole?
_____________________________________________________________________

7.    (a)    The facts of the most recent incident of sexual violence 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):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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      (b)    The facts of the most recent incident of intimidation are as follows:

Approximate Date: ______________________________________________________

Approximate Time: ______________________________________________________

Place: ________________________________________________________________

Describe in detail what happened, including medical treatment sought, and/or calls to
law enforcement (attach additional sheets of paper if necessary):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

8.       If Defendant has committed prior acts of sexual violence or intimidation against
Plaintiff, describe these prior incidents, and indicate approximately when such acts
occurred (attach additional sheets of paper if necessary):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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

10.    Is [there an]Plaintiff in immediate and present danger [for further acts of
sexual violence or intimidation] from Defendant[ against Plaintiff]? If so, please
describe: ______________________________________________________________


FOR THE REASONS SET FORTH ABOVE, I REQUEST THAT THE COURT ENTER A
TEMPORARY ORDER AND, AFTER A HEARING, A FINAL ORDER THAT WOULD
INCLUDE ALL OF THE FOLLOWING RELIEF (CHECK ALL FORMS OF RELIEF
REQUESTED):

   A. Restrain Defendant from having any contact with the victim, including, but not
limited to, entering the victim’s residence, place of employment, business, or school.

  B. Prohibit indirect contact through third parties.

  C. Prohibit direct or indirect contact with other designated persons.


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   D. Order Defendant to pay the fees of this action.

  E. Order the following additional relief, not listed above:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

    F. Grant such other relief as the court deems appropriate, including, but not limited
to, issuing an order under 42 Pa.C.S. § 62A11(b) related to the non-disclosure of the
victim's address, telephone number, whereabouts or other demographic information.

   G. 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 the hearing. Plaintiff will
inform the designated authority of any addresses, other than Defendant’s residence,
where Defendant can be served.

                                      VERIFICATION

       I verify that the statements made in this petition are true and correct to the best of
my knowledge. I understand that false statements herein are made subject to the
penalties of 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities.

_____________________________________________________________________
Signature
_____________________________________________________________________
Date


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