IN THE COURT OF COMMON PLEAS OF CLEARFIELD COUNTY, PENNSYLVANIA CIVIL DIVISION CRIMINAL RECORD / ABUSE HISTORY VERIFICATION
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1 IN THE COURT OF COMMON PLEAS OF CLEARFIELD COUNTY, PENNSYLVANIA CIVIL DIVISION CRIMINAL RECORD / ABUSE HISTORY VERIFICATION You must enter this information exactly as it appears on the custody complaint vs Plaintiff(s) Defendant(s) NO - -CD I, hereby swear or affirm, subject to penalties of law including 18 PaCS 4904 relating to unsworn falsification to authorities that 1 Unless indicated by my checking the box next to a crime below, neither I nor any other of my have been convicted, or pled guilty, or pled no contest, or was adjudicated delinquent where the record is publicly available pursuant to the Juvenile Act, 42 PaCS 6307, to any of the following crimes in Pennsylvania or a substantially equivalent crime in any other jurisdiction, including Check all that [ ] 18 PaCS Ch 25 [ ] [ ] (relating to criminal homicide) [ ] 18 PaCS 2702 [ ] [ ] (relating to aggravated assault) [ ] 18 PaCS 2706 [ ] [ ] (relating to terroristic threats) [ ] 18 PaCS [ ] [ ] (relating to stalking) [ ] 18 PaCS 2901 [ ] [ ] (relating to kidnapping) 1
2 [ ] 18 PaCS 2902 [ ] [ ] (relating to unlawful restraint) [ ] 18 PaCS 2903 [ ] [ ] (relating to false imprisonment) [ ] 18 PaCS 2910 [ ] [ ] (relating to luring a child into a motor vehicle or structure) [ ] 18 PaCS 3121 [ ] [ ] (relating to rape) [ ] 18 PaCS [ ] [ ] (relating to statutory sexual assault) [ ] 18 PaCS 3123 [ ] [ ] (relating to involuntary deviate sexual intercourse) [ ] 18 PaCS [ ] [ ] (relating to sexual assault) [ ] 18 PaCS 3125 [ ] [ ] (relating to aggravated indecent assault) [ ] 18 PaCS 3126 [ ] [ ] (relating to indecent assault) [ ] 18 PaCS 3127 [ ] [ ] (relating to indecent exposure) [ ] 18 PaCS 3129 [ ] [ ] (relating to sexual intercourse with animal) 2
3 [ ] 18 PaCS 3130 [ ] [ ] (relating to conduct relating to sex offenders) [ ] 18 PaCS 3301 [ ] [ ] (relating to arson and related offenses) [ ] 18 PaCS 4302 [ ] [ ] (relating to incest) [ ] 18 PaCS 4303 [ ] [ ] (relating to concealing death of child) [ ] 18 PaCS 4304 [ ] [ ] (relating to endangering welfare of children) [ ] 18 PaCS 4305 [ ] [ ] (relating to dealing in infant children) [ ] 18 PaCS 5902(b) [ ] [ ] (relating to prostitution and related offenses) [ ] 18 PaCS 5903(c) or (d) [ ] [ ] (relating to obscene and other sexual materials and performances) [ ] 18 PaCS 6301 [ ] [ ] (relating to corruption of minors) [ ] 18 PaCS 6312 [ ] [ ] (relating to sexual abuse of children) 3
4 [ ] 18 PaCS 6318 [ ] [ ] (relating to unlawful contact with minor) [ ] 18 PaCS 6320 [ ] [ ] (relating to sexual exploitation of children) [ ] 23 PaCS 6114 [ ] [ ] (relating to contempt for violation of protection order or agreement) [ ] Driving under the influence of drugs or alcohol [ ] [ ] [ ] Manufacture, sale, delivery, holding, offering for sale or possession of any controlled substance or other drug or device [ ] [ ] 2 Unless indicated by my checking the box next to an item below, neither I nor any other of my have a history of violent or abusive conduct including the following Check all that Self Other Date [ ] A finding of abuse by a Children & Youth Agency or similar agency in Pennsylvania or similar statute in another jurisdiction [ ] [ ] [ ] Abusive conduct as defined under the Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction [ ] [ ] [ ] Other [ ] [ ] 4
5 3 Please list any evaluation, counseling or other treatment received following conviction or finding of abuse 4 If any conviction above applies to a, not a party, state that person's name, date of birth and relationship to the child 5 If you are aware that the other party or s of the other party's has or have a criminal/abuse history, please explain ************** I verify that the information above is true and correct to the best of my knowledge, information or belief I understand that false statements herein are made subject to the penalties of 18 PaCS 4904 relating to unsworn falsification to authorities Signature Printed Name Date 5
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