231 Pa. Code r. 1915.17
(Caption)
NOTICE OF PROPOSED RELOCATION
You, ______ ,are hereby notified that _________ (party proposing relocation) ______ proposes to relocate with the following minor child(ren): _________.
To object to the proposed relocation, you must complete the attached counter-affidavit and serve it on the other party by certified mail, return receipt requested, addressee only, or pursuant to Pa.R.C.P. No. 1930.4 within 30 days of receipt of this notice. If there is an existing child custody case, you also must file the counter-affidavit with the court. If you do not object to the proposed relocation within 30 days, the party proposing relocation has the right to relocate and may petition the court to approve the proposed relocation and to modify any effective custody orders or agreements. FAILURE TO OBJECT WITHIN 30 DAYS WILL PREVENT YOU FROM OBJECTING TO THE RELOCATION ABSENT EXIGENT CIRCUMSTANCES.
Address of the proposed new residence: ___________________
___________________________________________________
[] Check here if the address is confidential pursuant to 23 Pa.C.S. § 5336(b).
___________________________________________________
Mailing address of intended new residence (if not the same as above) ___________________
___________________________________________________
[]Check here if the address is confidential pursuant to 23 Pa.C.S. § 5336(b).
Names and ages of the individuals who intend to reside at the new residence:
| Name | Age |
| _______________________________________ | |
| _______________________________________ | |
| _______________________________________ | |
| _______________________________________ | |
[] Check here if the information is confidential pursuant to 23 Pa.C.S. § 5336(b) or (c).
Home telephone number of the new residence: _________________
[] Check here if the information is confidential pursuant to 23 Pa.C.S. § 5336(b) or (c).
Name of the new school district and school the child(ren) will attend after relocation: ____________________________________
[] Check here if the information is confidential pursuant to 23 Pa.C.S. § 5336(b) or (c).
Date of the proposed relocation: ___________________________
[] Check here if the information is confidential pursuant to 23 Pa.C.S. § 5336(b) or (c).
Reasons for the proposed relocation: ________________________
____________________________________________________
____________________________________________________
Check here if the information is confidential pursuant to 23 Pa.C.S. § 5336(b) or (c).
Proposed modification of custody schedule following relocation:
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Other information: ______________________________________
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 CANNOTAFFORD 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.
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
(Caption)
COUNTER-AFFIDAVIT REGARDING RELOCATION
This proposal of relocation involves the following child/children:
| Child's Name | Age | Currently residing at: |
| __________ | ___ | ________________ |
| Child's Name | Age | Currently residing at: |
| __________ | ___ | ________________ |
| Child's Name | Age | Currently residing at: |
| __________ | ___ | ________________ |
I have received a notice of proposed relocation and (check all that apply):
1.[] I do not object to the relocation.
2.[] I do not object to the modification of the custody order consistent with the proposal for modification set forth in the notice.
3.[] I do not object to the relocation, but I do object to modification of the custody order.
4.[] I plan to request that a hearing be scheduled by filing a request for hearing with the court:
a.[] Prior to allowing (name of child/children) to relocate.
b.[] After the child/children relocate.
5.[] I do object to the relocation.
6.[] I do object to the modification of the custody order.
I understand that in addition to objecting to the relocation or modification of the custody order above, I must also serve this counter-affidavit on the other party by certified mail, return receipt requested, addressee only, or pursuant to Pa.R.C.P. No. 1930.4, and, if there is an existing custody case, I must file this counter-affidavit with the court. If I fail to do so within 30 days of my receipt of the proposed relocation notice, I understand that I will not be able to object to the relocation at a later time.
I verify that the statements made in this counter-affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities).
| _____ | _________ |
| (Date) | (Signature) |
231 Pa. Code r. 1915.17