Chest. Cnty. Ct. Comm. Plea. R., form 15
See CCRCP 1915.11-1.A.(b)(4)(i): form req'd by CCRCP 1915.11-1.A(b)
AFFIDAVIT - ATTORNEY
I, ________________________, the undersigned applicant, hereby certify that I possess the minimum qualifications to serve as a Parenting Coordinator as established by Pa.R.Civ.P. 1915.11-1.(b)(1),(2), as follows:
1. ______I am licensed to practice in the Commonwealth of Pennsylvania. My Attorney ID number is _____________.
_______My license is in good standing.
________I have never been subject to attorney discipline. (If Applicant has been subject to discipline, provide details on separate sheet).
________I have practiced Family Law for ______years, as follows (or attach CV):
__________________________________________________________
__________________________________________________________
__________________________________________________________
2. ________I have obtained the special training required by the Rule and have attached verification for each training:
______hours in the Parenting Coordination process, of which 2 or more hours were specific to Pennsylvania PC practice.
Date of training: _________________________
Provider: ______________________________
______hours of Family mediation (or hours of non-specific mediation training and hours of Family Mediation conducted).
Date of training: ________________________
Provider: ______________________________
______hours of Domestic Violence training.
Date of training: ________________________
Provider: ______________________________
3. _________I understand that to remain qualified as a Parenting Coordinator in each 2-year period after March 1, 2019, I must take a minimum of 10 additional continuing education credits, of which at least 2 must be on domestic violence.
4. _________I maintain Professional Liability insurance of $___________, which coverage expressly covers me for serving as a Parenting Coordinator. The Declaration page showing the foregoing is attached.
1. acknowledge that I may not charge more than $300 per hour (although I may charge less), nor require more than a $1000 initial retainer. My hourly rate for Parenting Coordination is: $____________.
2. ________I acknowledge I must accept one pro bono PC appointment for every 2 fee-generating appointments in this judicial district/county, up to 12 hours per pro bono case. I understand that it is my responsibility to advise the court upon acceptance of the second appointment. I further understand that failing to accept a pro bono assignment or to notify the Court is grounds for removal from the roster maintained by this county.
3. ________I have read Pa.R.Civ.P. 1915.11-1 and understand the scope (and) limits of my authority and the procedures which I must follow when appointed as a Parenting Coordinator.
4. ________I acknowledge that I have read the Guidelines for Parenting Coordination promulgated by the American Psychological Association and Association of Family and Conciliation Court.
https://www.apa.org/practice/guidelines/parenting-coordination
https://www.afccnet.org/Resource-Center/Practice-Guidelines
I swear or affirm that the foregoing statements are true and correct.
APPLICANT:
Name (printed) _______________________
Signature ___________________________
Date: ___________________
FOR OFFICIAL USE ONLY
Qualifications Reviewed by : ______________(initials)
Place application on Roster: Yes _____________ No __________
If No, state reasons:
________________________________________________
________________________________________________
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Chest. Cnty. Ct. Comm. Plea. R., form 15