Chest. Cnty. Ct. Comm. Plea. R., form 4
See CCRCP 1905.A.(c): form req'd by CCRCP 1901.5.A.(a)
IN THE COURT OF COMMON PLEAS OF CHESTER COUNTY, PENNSYLVANIA
Plaintiff | : No. |
: | |
v. | : Civil Action |
: Indirect Criminal Contempt | |
Defendant | : for Violation of Protection From Abuse Order |
COMPLAINT
I, the undersigned, do hereby state under oath:
1. My name is ___________________________________________and I live/work at
________________________________________________;
2. I accuse _________________________________________, who lives at
____________________________________________________, with violating a protection from abuse order entered by Judge ______________on the______day of ____________, 20____ (attach copy of order if available);
3. The date (and day of the week) when the accused committed the offense was on or about _____________________________________________________________.
4. The place where the offense was committed was in the County of Chester;
5. The acts committed by the accused were: (place an X before the appropriate statement(s)) _____attempting to cause or intentionally, knowingly or recklessly causing bodily injury to_________________________________________
-or
_____using physical menace to put _________________________in fear of imminent serious bodily injury,
all of which were in violation of the protection from abuse order entered in accordance with the Protection from Abuse Act, 23 Pa.C.S. § 6101et seq .;
6. If the defendant has not already been arrested, I ask that a warrant of arrest be issued and that the accused be required to answer the charges I have made.
I verify that the statements made in the complaint are true and correct to the best of my knowledge, information and belief. I further understand that any false statements made herein are subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.
Date __________________ Signature of Affiant ____________________
The above subscribed affiant personally appeared before me on this date, signed the complaint in my presence and asserted that the facts therein are true and correct; and wherefore it appears that there is probable cause for the issuance of process.
Date __________________ Issuing Authority ___________________________________(SEAL)
Chest. Cnty. Ct. Comm. Plea. R., form 4