Fill and Sign the Would You Disclose Buyers Name to Receiver General Selling Form

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: CAUTION:  Weapon Involved  Weapon Present on the Property  Weapon Requested Relinquished Defendant's Place of employment is:  Check here if you have reason to believe that Defendant is a licensed firearms dealer, employed by a licensed firearms dealer ormanufacturer; 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 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 a ppointment 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:PETITION FOR PROTECTION IN THE COURT OF COMMON FROM ABUSE PLEAS OF COUNTY, PENNSYLVANIA NO. DEFENDANT IDENTIFIERS DOB HEIGHT SEX WEIGHT RACE EYES HAIR SSN DRIVERS LICENSE # EXP DATE STATE 5. Indicate the relationship between Plaintiff and Defendant :CHECK ALL THAT APPLY: spouse or former spouse of D efendant parent of a child with Defendant curren t or former sexual or intimate partner with Defendant child of Plaintiff child of D efendant family member related by blood (consanguinity) to Defendant family member related by marriage or affinity to De fendant sibling (person who shares parenthood) of Defendant Check here if 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 existing court order regarding their custody? If you answered "Yes," describe the terms of the order (e.g., primary, shared, legal 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(sF child Address, unless When l ived with confidential (bF 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(sF 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: Describe in detail what happened, including any physical or sexual abuse, threats, injury, incidents of stalking, medical treatment sought, or calls to law enforcement. (attach additional sheets of paper if necessary): 12. If 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 a cts 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 o n Attachment A to Petition, which is incorporated by reference into this p etition, any firearms, other weapons , or ammunition Defendant used or threatened to use against Plaintiff or the minor child/ren: (b) Other than the firearms, other weapons , or ammunition Defendant used orthreatened to use against 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 a nswer to (b) abov e is “yes,” li st an y additiona l firearm , other weapon , or ammunitio n owne d by or in th e p osse ssion of Defendan t on Attachment A to Petition , which is incorporate d by reference i n to this petition. (d) Plaintif f (check one ) DOES DOE S NOT reque st tha t the co urt order Defendan t to re linqu ish firearms , other weapons , or ammunitio n listed on Attachmen t A to Petition. If Plaintiff does seek relinquishment, identify on Attachment A to Petition the firearms, other weapons or ammunition Plaintiff requests the court to order Defendant to relinquish. 1 4. Identif y the sh e riff , police department , or law enforcemen t agency in the a rea i n wh ich Plain tiff lives tha t should be provide d with a c opy o f the protect ion order: 15. There is an immediate and present danger of further abuse from Defendant. CHE CK THE FOLLOWIN G BOXES ONLY IF THEY APPLY TO YOUR CASE AND PROVIDE THE REQUESTED INFORMATION Plaintiff is asking the court to evict and exclude 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 or the minor child/ren: Plaintiff has suffered out- of-pocke t financial losses as a re sult o f 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 FOLLOWI NG (CHECK ALL FORMS OF RELIEF REQUESTED) A. Restrain Defendant from abusing, harassing, stalking, threatening ,attempting or threatening to use physical force against Plaintiff or the minor child/ren in any place where Plaintiff 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 or the minor child/ren withother 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 or the minor child/ren, 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 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 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. Name Address (optional) Relationship to Plaintiff G. Order Defendant to temporarily relinquish the firearms, other weapons , or ammunition listed on Attachment A to Petition, under Defendant’s control, or in Defendant’s possession, or any firearm license to the sheriff or the appropriate law enforcement agency. H. Prohibit Defendant from acquiring or possessing firearms for theduration of the order. I . Order Defendant to pay temporary support for Plaintiff or the minor child/ren, including medical support and payment of the rent or mortgage on the residence. J . Direct Defendant to pay Plaintiff for the reasonable financial losses suffered as the result of the abuse, to be determined at the hearing. fees. N. Grant such other relief as Plaintiff requests or the court deems appropriate O. Order the police, sheriff, or other law enforcement agency to serve 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 Defendant's residence, where Defendan t 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 K. Order Defendant to pay the costs of this action, including filing and service L. Order Defendant to pay Plaintiff's reasonable attorney's fees. M. Order the following additional relief, not listed above: Defendant, if Plaintiff has reason to believe his or her safety is at risk. VERIFICATION I verify tha t I am the petitioner as designated in the presen t action and tha t the fa cts and statemen ts contained in the above Petition are true and corre ct to the bes t o f my knowledge. I understand that any false statements are made subject to the penalties of 18 Pa. C.S. § 4904, relating to unsworn falsification to authorities Signature Date (Caption) ATTACHMENT A TO PETITION FIREARMS, OTHER WEAPONS, 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, or ammunition against Plaintiff 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. (b) state tha t Defendant , to the be st o f 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, or ammunition (include addresses or locations, if known): Firearm/Othe r Weapon/Ammunition Location 1. 2. 3. 4. 5.5. □ All firearms, other weapons , 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.