Fill and Sign the Extended Order Form

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: CAUTION:  Weapon Involved  Weapon Present on the Property  Weapon Ordered Relinquished The Court Hereby Finds: That it has jurisdiction over the parties and subject matter, and Defendant has been provided with reasonable notice and opportunity to be heard. The Court Hereby Orders:  Defendant shall not abuse, harass, stalk, threaten, or attempt or threaten to use physical force against any of the above persons inany place where they might be found.  Except as provided in Paragraph 5 of this order, Defendant shall not contact Plaintiff, or any other person protected under thisorder, 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 DEFENDANT 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 , 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. § 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 . FINAL PROTECTION FROM ABUSE ORDER Extended Order Amended Order DEFENDANT IDENTIFIERS DOB HEIGHT SEX WEIGHT RACE EYES HAIR SSN DRIVERS LICENSE # EXP DATE STATE IN THE COURT OF COMMON PLEAS OF COUNTY, PENNSYLVANIA NO. CHECK ALL THAT APPLY : Plaintiff or Protect ed 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 Defe ndant 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. Withou t regard as to how the order was entered, this is a final orde r of court subje ct to full enforcement pursuan t to the Protection From Abuse Act. Note : Space is provided to allow for 1) the court's gene ral findings o f 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 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) information that may be helpful to law enforcement (e.g., whether a firearm or other weapon was involved in the incident of abuse or whether Defendant is believed to be armed and dangerous).  Plaintiff's request for a final protection order is deni ed. 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 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 an y 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 orde r.  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 co nditions]:  3. Except as provided in 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 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)  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.  6.The custody provisions of Paragraph 5 of this order are temporary. Either party may initiate custody proceedings pursuant to the custody statute at 23 Pa.C.S. §§ 5321 — 5340 . Any valid custody order entered after the final Protection From Abuse order supersedes the custody provisions of this order. FIREARMS, OTHER WEAPONS, OR AMMUNITION RE STRICTIONS Check all that apply:  Defendant is prohibited from possessing 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 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 ma y either relinquish firearms, other weapons , 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 , or ammunition to a li censed firearms dealer for consignment sale, lawful transfer, or safekeeping pursuant to 23 Pa.C.S. § 6108.2(e). Defendant must relinquish any firearm, other weapon, ammunition , or firearm license ordered to be relinquished no later than 24 hours after serv ice of this order. Failure to timely relinqu ish 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. § 6105.  7. Any firearm delivered to the sheriff or the appropriate law enforcementagency 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. § 6108.3 pursuant to this order or the temporary order, shall not be returned to Defendan t until further orde r of court or as ot herwise 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. §2709.1, or harassing, as defined in 18 Pa.C.S. § 2709, the following family and household m embers of Plaintiff: Name Address (optional) Relationship to Plaintiff  Other relief:  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 corre ct 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. □ (a) The costs of thi s action are imposed on Defendant.  (b) Because this order followed a contested proceeding, or a hearing at wh ich Defendant was no t present, despite being served with a co py of the petition , temporary order and notice of the date, time and place of the hearing , Defendan t 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. §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.  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 THb PETITION SHOULD BE PRESENTED] requesting recovery of out - of - pocket losses. The petition shall include an exhibit itemizing all claime d 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.  13. THIS ORDER SUPERSEDES ANY PRIORPROTECTION FROM ABUSE ORDER OBTAINED BY THE SAME PLAINTIFF AGAINST THE SAME DEFENDANT. 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 EX PIRATION DATE]11. 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. § 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 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. § 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 NOTICE TO DEFENDANT no t 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 This order was entered pursuant to the consent of Plaintiff and Defendant :Plaintiff’s Signature Defendant’s Signature (Caption) ATTACHMENT A T O 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. § 6108(a)(7)(v). * * *