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Free Pennsylvania Divorce Form

Forms in Divorce

If you want to file for divorce in the state of Pennsylvania you can use this document as a template or self-help form to help you fill the divorce form.

This document contains a lot of things starts out with a disclaimer and then goes into the introduction. The introduction a big picture of what exactly a divorce is, what are the ramifications of going through with the divorce, advice as to if you should speak to an attorney and why you need to do that, and the things you need to know if you decide to represent yourself in the divorce action.

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A few pages into this document you’ll find the page titled definitions. This page lists a large number of words that are in this document and explains the meanings behind each of these words in context of the document.

After that the document gives you a complete the complete rundown of the do’s and don’ts while filing this divorce petition. It does this in the form of a list of frequently asked questions and answers them the best of its ability.

Then part five of this document contains the names of each and every form that you might need in the filing of this divorce petition. But six states called the rules that had to be followed by both parties during the filing of this divorce petition. This document can prove to be very helpful as it has all the details and information that one can need to file this divorce petition. This divorce petition document/form is only applicable in the state of Pennsylvania.

Pennsylvania Divorce Form

Text version of this Form

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HOW TO FILE FOR DIVORCE

Disclaimer by the Court of Common Pleas of Lancaster County, Pennsylvania

Neither the staff in the Center nor the staff in any Court office will be able to give you legal
advice or help you fill out/complete the forms. The information in the packets is not a substitute
for professional legal advice. The Court assumes no responsibility and accepts no liability for
actions taken by users of these documents, including reliance on their contents. If you want to
obtain the services of an attorney but do not know whom to contact, you may call the Lawyer
Referral service at 393-0737.

Revised 09/26/12

©2011 Judge Henry S. Kenderdine, Jr. Court Self Help Center

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DIVORCE PACKET

I. INTRODUCTION

II. DEFINITIONS

III. FREQUENTLY ASKED QUESTIONS

IV. PROCEDURES

V. FORMS

VI. RULES

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I. INTRODUCTION.
A divorce is a way to legally end your marriage. It is recommended that you at
least speak to an attorney so you know your legal rights.

If you decide to represent yourself in the divorce action (known as “pro se”), it
will take a lot of time, and cause you difficulty, confusion, and frustration. You MUST
follow the Rules and Procedures, both state and county, as are required for attorneys. The
Court will not allow you to skip any procedure because you “did not know how or
when” to do something in your divorce action. This packet is not to be a substitute for
professional legal advice tailored to a specific fact situation.

Speaking with an attorney is absolutely recommended if you wish to bring up
issues besides legally ending your marriage – such as making claims to items of
property and other money from your marriage or for alimony after divorce.

Also, this self help packet contains instructions only about how to obtain a
“no-fault” divorce. Pursuing a divorce on one of the fault grounds in Pennsylvania
divorce law requires litigation before a court appointed Divorce Master. Therefore,
if a fault based divorce is desired, the assistance of an attorney is strongly
recommended.

PLEASE NOTE-DO NOT SUBM IT AN INCOM PLETE COM PLAINT . IF YOUR COM PLAINT
DOES NOT CONTAIN ALL OF THE REQUIRED INF ORM ATION, IT W ILL BE REJE CTED BY
THE CO UR T. IF TH E CO M PLAIN T IS REJECTED , YO U M AY BE R EQU IRED TO RE-FILE
Y OUR P ETITION A ND PAY T H E F ILIN G F EE A GA IN .

COURT-STAFFED OFFICES IN THE COURTHOUSE ARE NOT PERMITTED
TO GIVE YOU LEGAL ADVICE.

Also, the Judges and Divorce Masters WILL NOT be available to you to
provide advice or guide you through the proceedings. You are NOT ALLOWED to
contact Judges or Divorce Masters except for filing official paperwork or appearing
in court proceedings.

If you feel you need an attorney, you may contact the LANCASTER BAR
ASSOCIATION. Telephone: (717)393-0737.

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II. DEFINITIONS.

“Alimony” An Order for support granted by this Commonwealth or any other state to
a spouse or former spouse in conjunction with a Decree granting a divorce
or annulment.

“Alimony Pendente Lite” (APL)
An Order for temporary support granted to a spouse during the pendency
of a divorce or annulment proceeding.

“Annulment”
Act of making a marriage void retrospectively as well as prospectively;
annulment destroys existence of void or voidable marriage, which factors
are found in 23 Pa.C.S.A. §3304 and 23 Pa.C.S.A. §3305.

“Cohabitation”

Living or abiding or residing together as man and wife.

“Contested divorce”

A divorce where the parties do not agree to a division of property and/or to
divorce.

“Counterclaim”

An answer to the complaint filed by the Defendant in the same action,
which may raise any other matter under the Divorce Code that may be
joined with the divorce .

“Defendant” The person being sued.

“Divorce” Divorced from the bonds of matrimony.

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“Divorce Master”

An attorney appointed by the court to hear testimony on claims filed in a
divorce action and make recommendations for resolution of those claims.

“Equitable” Does not mean “equal.”

“Ex parte” In order to preserve fairness to all in a proceeding, no one party or his/her
lawyer can contact the court about issues in the case without the other
party’s participation; this includes by telephone, mail, or in person.

“Fault divorce”

A divorce filed under 23 Pa.C.S.A. §3301(a) or (b).

“Grounds for divorce”

The grounds are enumerated in §3301 of the Domestic Relations Code
(relating to grounds for divorce).

“Irretrievable breakdown”

Estrangement due to marital difficulties with no reasonable prospect of
reconciliation.

“Jurisdiction”

The courts shall have original jurisdiction in cases of divorce and for the
annulment of void or voidable marriages and shall determine, in
conjunction with any decree granting a divorce or annulment, the
following matters, if raised in the pleadings, and issue appropriate decrees
or orders with reference thereto, and may retain continuing jurisdiction
thereof:

(1) The determination and disposition of property rights and interests
between spouses, including any rights created by any antenuptial,
postnuptial, or separation agreement and including the partition of
property held as tenants by the entireties or otherwise and any accounting

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between them, and the order of any spousal support, alimony, alimony
pe ndente lite, counsel fees or costs authorized by law.

(2) The future care, custody and visitation rights as to children of the
marriage or purported marriage.

(3) Any support or assistance which shall be paid for the benefit of any
children of the marriage or purported marriage.

(4) Any property settlement involving any of the matters set forth in
paragraphs (1), (2) and (3) as submitted by the parties.

(5) Any other matters pertaining to the marriage and divorce or annulment
authorized by law and which fairly and expeditiously may be determined
and disposed of in such action.

“Marital property”

All property acquired by either the husband or the wife during the
marriage. It also means any gain in value of the non-marital property from
the date of the marriage until the date of final separation.

“No-fault divorce”

A divorce filed under 23 Pa.C.S.A. §3301(c) or (d).

“Non-marital property”

Property owned before marriage or property acquired in trade for property
owned before the marriage; property you and your spouse agree is not
marital property; property acquired as a gift (except between spouses) or
an inheritance; property acquired between the final separation date and the
date of divorce; property a spouse traded or sold for value or gave away in
good faith before the date of final separation; certain veteran’s benefits;
property mortgaged in good faith and for value before the date of the final
separation; and payment received from a claim which arose before the
marriage or after the date of final separation.

“Pro se” For one’s own behalf or appearing for oneself.

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“Plaintiff” The person filing the case.

“Qualified professionals”

Includes marriage counselors, psychologists, psychiatrists, social workers,
ministers, priests, rabbis or other persons who, by virtue of their training
and experience, are able to provide counseling.

“Separate and apart”

Complete cessation of any and all cohabitation, whether living in the same
residence or not.

“Spousal support”

Care, maintenance and financial assistance.

“Uncontested Divorce”

A divorce where the parties agree, and is filed under 23 Pa.C.S.A.
§3301(c) or (d).

“Venue” A proceeding for divorce or annulment must be brought in the county (1)
where the Defendant resides; (2) if the Defendant resides outside of this
Commonwealth, where the Plaintiff resides; (3) of matrimonial domicile,
if the Plaintiff has continuously resided in the county; or (4) prior to six
months after the date of final separation and with agreement of the
Defendant, where the Plaintiff resides, or if neither party continues to
reside in the county of matrimonial domicile, where either party resides; or
(5) after six months after the date of final separation, where either party resides.

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III. FREQUENTLY ASKED QUESTIONS.

What court costs/fees are involved to file a divorce? See Schedule of
Prothonotary’s Fees. The fees must be paid at the beginning of the case.

Can I get a “legal separation”? In Pennsylvania, there is no statute for a legal
separation.

Who may file for divorce? In order for the Commonwealth of Pennsylvania to
have jurisdiction over your divorce, either you or your spouse must have lived in
Pennsylvania for at least six (6) months or have been stationed in Pennsylvania as
a member of the military for at least six (6) months.

How long does it take to get a divorce? There is no certain answer. Each case is
different.

If the spouses agree to divide their property or have no property and are in agreement
with the divorce, the divorce can become final in approximately four (4) months. Refer
to 23 Pa.C.S.A. §3301(c) and Pa.R.C.P. 1920. 1 through 1920.76.

If one spouse does not agree, the divorce can be prolonged in excess of two (2) years or
more from the date of separation under §3301(d) of the Divorce Code. Refer to 23
Pa.C.S.A. §3301(d) and Pa. R.C.P. 1920.1 through 1920.76.

Can I get a divorce if I am married by common law? See a lawyer.

I live in another county, can I get divorced in Lancaster County? Yes,
however, the parties must agree in writing or participate in the proceeding. Refer to Pa.
R.C.P. No. 1920.2(a)(2). Otherwise, if the parties do not agree, the divorce action must
be filed in the proper county. It is always proper to file the action in the county in which
the Defendant resides.

Can I get divorced if I do not know my spouse’s whereabouts? See a lawyer.

What are the grounds for divorce? Refer to 23 Pa.C.S.A. §3301.

What are the procedures and timelines? Provided in the following section but

for a “no-fault” divorce only. (See page 2).

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What is the difference between spousal support, alimony pendente lite, and

alimony? See below.

WHAT IS SPOUSAL SUPPORT? 23 Pa.C.S.A. §4321.

Spousal supp ort originates from the Pennsylvania support law, which states that

married persons are liable for the support of each other according to their respective

abilities to provide support, as provided by law. Generally, the spouse with the higher

income or earning capacity will be ordered to pay a periodic amount of spousal support to

the spouse who earns less. The spouse who earns less often is referred to as a dependent

spouse.

HOW DO I FILE FOR SPOUSAL SUPPORT?

Pa.R.C.P. 1910.4; 1910.27(a)

Spousal support cases are filed at the Domestic Relations Section and follow the

procedure for support cases.

HOW IS THE AMOUNT OF SPOUSAL SUPPORT DETERMINED?

Pa.R.C.P. 1910.16-1 through 1910.16-7

23 Pa.C.S.A. §4322

Spousal support is determined through a clear cut guideline calculation based on

the parties’ incomes set forth in the Pennsylvania support guidelines.

AND IF YOUR SPOUSE GETS WELFARE CASH ASSISTANCE . . .?

23 Pa.C.S.A. §§4378; 4379; 4306(b.1)

A spouse who applies and qualifies for cash benefits from the Pennsylvania

Department of Public Welfare (DPW) is required to file a spousal support claim against

his or her spouse as a condition of receiving the cash assistance from DPW. This DPW

filing requirement is imposed regardless of the wishes, inclination, or conduct of the

filing spouse.

WHEN DOES SPOUSAL SUPPORT STOP?

Pa.R.C.P. 1910.16-5(b)

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A spousal support award terminates upon the entry of a divorce decree, although a

court may terminate it sooner due to the duration of the parties’ marriage or modify an

award due to a change in circumstances.

IS THERE ANY WAY TO DEFEAT A SPOUSAL SUPPORT CLAIM?

No legal citation – case law defines the issue

A claim for spousal support may be defeated through what is known as the

entitlement defense. The entitlement defense obligates the spouse who left the marital

residence to prove that his or her leaving the marriage was justified. That person will

have the burden of convincing a court the other spouse engaged in a course of conduct in

line with one of the grounds for fault divorce. If the entitlement defense is invoked at the

initial Domestic Relations conference, the conference officer will schedule the matter for

a hearing before a Common Pleas Court judge.

Dependent spouses who live with an unrelated member of the opposite sex

typically are not successful in receiving a spousal support award from the court.

AND HOW IS APL DIFFERENT?

23 Pa.C.S.A. §3702

HOW IS THE AMOUNT OF APL DETERMINED?

Pa.R.C.P. 1910.16-1 through 1910.16-7

Like spousal support, APL is determined through a clear cut guideline calculation

based upon the parties’ incomes, using Pennsylvania’s support guidelines.

MAY I USE AN ENTITLEMENT DEFENSE TO COUNTER AN ALIMONY

PENDENTE LITE CLAIM?

No, unlike spousal support, the entitlement defense is not applicable to APL

proceedings.

WILL WELFARE MAKE MY SPOUSE FILE AN APL CLAIM?

No. DPW does not require APL filings.

DO I FILE FOR APL AT DOMESTIC RELATIONS?

Since APL originates from the Divorce Code, an APL claim first needs to be filed

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in a divorce action at the Office of the Prothonotary. Then, a Complaint or petition

seeking APL must be filed with the Domestic Relations Section, and Domestic Relations

will schedule the APL claim for a support conference where the APL award will be

calculated according to the Pennsylvania support guidelines.

WHEN DOES APL STOP?

APL awards are modifiable by the court after a showing of change of

circumstances. APL awards typically terminate upon resolution of all claims raised in a

divorce action.

WHAT IS ALIMONY?

23 Pa.C.S.A. §3701

Alimony is a claim that originates from the Pennsylvania Divorce Code whereby a

dependent spouse can request a periodic support payment from his or her spouse so they

might maintain themselves after the entry of a divorce decree. Alimony payments do not

start until all claims raised in a divorce are resolved. Since alimony originates from the

Divorce Code, an alimony claim needs to be filed in a divorce action at the Office of the

Prothonotary. Alimony may not be filed at the Domestic Relations Section. Alimony is

established by testimony and other evidence relating to statutory factors presented at a

hearing before a Divorce Master.

Al imony pendente lite (APL) is a claim that originates from the Pennsylvania

Divorce Code whereby a dependent spouse can request a periodic support payment from

his or her spouse so they are able to maintain themselves during the pendency of a

divorce action. Like spousal support, the spouse with the higher income or earning

capacity will be ordered to pay an amount of APL to their dependent spouse. A court will

not award both spousal support and APL during the same time.

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IV. PROCEDURES – (A) SIMPLE NO FAULT DIVORCE UNDER §3301(C)
OF THE DIVORCE CODE – IF BOTH PARTIES AGREE:

FILING

A divorce case is started with the filing of a “Complaint.” Refer to Pa. R.C.P. 1920. 12.
All filings require the original plus two copies of the Complaint. The original stays with
the court and two copies are returned to you; one for you and one for the other spouse.
An accompanying civil cover sheet is to be included with the Complaint. (See form 1.)
Pay a filing fee to the Prothonotary’s Office, located in the Courthouse. (See Schedule of
Costs.) The Prothonotary shall file the original, assign a case number and return two (2)
timed-stamped copies to you.

SERVICE

Service of the Complaint must be made by either personal service (form 2A or 2b) or
certified mail (form 3) in accordance with Pa. R.C.P. 1930.4.
A copy of the Divorce Complaint must be served upon the other party within thirty (30)
days. Refer to Pa. R.C.P. No. 1930.4(e). Otherwise, the Complaint must be reinstated
and re-served in accordance with Pa. R.C.P. 1930.4(g).

FINALIZATION

After ninety (90) days have passed from the date the Complaint was served upon the
other spouse and both parties agree to the divorce, both parties must file an Affidavit of
Consent (form 4a and b) and Waiver of Notice of Intention to Request Entry of Divorce
Decree (form 5a and b) in accordance with Pa. R.C.P. 1920.42(b)(1). The Waiver of
Notice and Affidavit of Consent, in accordance with Pa. R.C.P. 1920.42(b)(2), must be
filed within thirty (30) days after that Affidavit was signed and dated. (Refer also to Pa.
R.C.P. 1920.72(b)(c).)
Upon the filing of both parties’ Affidavits of Consent and Waivers of Notice of Intention
to Request Entry of Divorce Decree with the Court, the divorce may be concluded by
either party filing with the court, a Praecipe to Transmit the Record (form 6) and
Praecipe of service (form 7), four (4) copies of the proposed Divorce Decree (form 9),
and accompanying state statistical form (form 10). Refer to Pa. R.C.P. 1920.46. You
must also provide the court with self-addressed and stamped envelopes for yourself and
your spouse.

NO TE: The Divorce Decree will be mailed to both parties app roximately
fo urteen (14) d ays aft er filing the above forms, presuming there are no
deficiencies. You may check the docket online at: www.co.lancaster.pa .us

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PROCEDURES – (B) SIMPLE NO FAULT DIVORCE UNDER §3301(D) OF THE
DIVORCE CODE – TWO-YEAR SEPARATION:

FILING

A divorce case is started with the filing of a “Complaint.” Refer to Pa. R.C.P. 1920. 12.
All filings require the original plus two copies of the Complaint. The original stays with
the court and two copies are returned to you; one for you and one for the other spouse.
An accompanying civil cover sheet is to be included with the Complaint. (See form 1.)
Pay a filing fee to the Prothonotary’s Office located in the Courthouse. (See Schedule of
Costs.) The Prothonotary shall file the original, assign a case number and return two (2)
timed-stamped copies to you.

SERVICE

Service of the Complaint must be made by either personal service (form 2A or 2b) or
certified mail (form 3) in accordance with Pa. R.C.P. 1930.4.
A copy of the Divorce Complaint must be served upon the other party within thirty (30)
days. Refer to Pa. R.C.P. No. 1930.4(e). Otherwise, the Complaint must be reinstated
and re-served in accordance with Pa. R.C.P. 1930.4(g).

FINALIZATION

Pursuant to Pa. R.C.P. 1920.42(a)(2), and after two (2) years following separation of the
parties have passed, either party may sign an Affidavit under §3301(d) of the Divorce
Code (form 11), file an original and two copies with the Prothonotary’s Office, and serve
a copy upon the other spouse. Service of the Affidavit may be made by first class mail.
After service has been made, the original Certificate of Service (form 11a) must be filed
in the Prothonotary’s Office.
Pursuant to Pa. R.C.P. 1920.42(d)(1), and twenty (20) days after the Affidavit under
§3301(d) of the Divorce Code referred to immediately above has been filed with the
Prothonotary’s office and served upon the other spouse, a Notice of Intention to Request
Entry of Divorce Decree (form 12) and copy of prop osed Praecipe to Transmit the
Record (form 6) is filed with the Prothonotary’s Office and served upon the other spouse
and any attorney of record along with a Certificate of Service (form 1 1a) listing all
persons you have so served. Service of this Notice may be made by first class mail.

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Pursuant to Pa. R.C.P. 1920.46 and 1920.73, and upon twenty (20) days after the Notice
referred to immediately above has been filed and served upon the other spouse, the
divorce may be concluded by either party filing with the court, the original Praecipe to
Transmit the Record (form 6) and Praecipe of service (form 7), four (4) copies of the
proposed Divorce Decree (form 9), and accompanying state statistical form (form 10).
Also, if the Defendant has not filed any papers related to the action, the Plaintiff must
file an Affidavit of Nonmilitary Service (form 8). (See Pa.R.C.P. 1920.46) You must
also provide the court with self-addressed and stamped envelopes for yourself and your
spouse.

NO TE: The Divorce Decree will be mailed to both parties approximately fourteen
(14) days after filing the above form s, presu ming there are no deficiencies. You may
check the docket online at: www.co.lancaster.pa.us

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V. FORMS:

# NAME OF FORM

1. COMPLAINT UNDER §3301(C) OR (D) OF THE DIVORCE
CODE AND CIVIL COVERSHEET

2(a). SERVICE DOCUMENT BY PERSONAL SERVICE

2(b). SERVICE DOCUMENT BY ACCEPTING SERVICE

3. SERVICE DOCUMENT BY CERTIFIED MAIL

4(a). AFFIDAVIT OF CONSENT FOR PLAINTIFF’S SIGNATURE

4(b). AFFIDAVIT OF CONSENT FOR DEFENDANT’S SIGNATURE

5(a). WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY
OF DIVORCE DECREE UNDER §3301(C) OF THE DIVORCE
CODE FOR PLAINTIFF’S SIGNATURE

5(b). WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY
OF DIVORCE DECREE UNDER §3301(C) OF THE DIVORCE
CODE FOR DEFENDANT’S SIGNATURE

6. PRAECIPE TO TRANSMIT THE RECORD

7. SERVICE FORM FOR PRAECIPE TO TRANSMIT THE
RECORD

8. AFFIDAVIT OF NONMILITARY SERVICE

9. DIVORCE DECREE

10. STATE STATISTICAL FORM

11. AFFIDAVIT UNDER §3301(D) OF THE DIVORCE CODE

11(a). CERTIFICATE OF SERVICE OF AFFIDAVIT UNDER
§3301(D) OF THE DIVORCE CODE.

12. NOTICE OF INTENTION TO REQUEST ENTRY OF
DIVORCE DECREE UNDER §3301(D) OF THE DIVORCE
CODE

13. COMPLAINT WITH COUNT I – ALIMONY PENDENTE LITE

NOTE: PLEASE SEE LOCAL RULE NO. 205.2(a) PHYSICAL
CHARACTERISTICS OF LEGAL PAPERS

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VI. RULES

Rules pertaining to divorce can be found in the Pennsylvania Rules of Court
beginning at Rule No. 1920.1 through 1920.75.

Rules pertaining to divorce can be found in the Lancaster County Local Rules
specifically Rules No. 252.2(a) and 252.2(b).

A copy of the Pennsylvania and local Lancaster County Rules of Court can be
found at the Lancaster County Law Library.

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SCHEDULE OF DIVORCE C OSTS:
COSTS ARE SUBJECT TO CHANGE – CHECK ONLINE AT:
www .co.lancaster.pa.us

Divorce – 3301(c) or (d) (No Fault) Fees $190.50
include: Writ, tax, JCP, AOPC, CTF,
PAF & Order)

Each Additional Count for a claim $51.75

If Count is for Custody, add AOPC fee $ 7.50

Master’s Fee (for each one-half day) $475.00
Special Note: Master’s fees are non-
refun dable

NOTE: All fees are to be paid by money order, cashiers check, personal check or
cash. A money order or check should be made payable to the Lancaster County
Prothonotary.

*** Filing a divorce – fee includes initial filing, PAF and Final costs

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IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

In Re: The marriage of :
:
___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

NOTICE TO DEFEND AND CLAIM RIGHTS

You have been sued in court. If you wish to defend against the claims set forth in the following
pages, you must take prompt action. You are warned that if you fail to do so, the case may proceed
without you and a decree of divorce or annulment may be entered against you by the court. A judgment
may also be entered against you for any other claim or relief requested in these papers by the plaintiff.
You may lose money or property or other rights important to you, including custody or visitation of your
children.

When the ground for the divorce is indignities or irretrievable breakdown of the marriage, you
may request marriage counseling. A list of marriage counselors is available in the Office of the
Prothonotary at the Lancaster County Courthouse, 50 North Duke Street, 2nd floor, Lancaster,
Pennsylvania.

IF YOU DO NOT FILE A CLAIM FOR ALIMONY, DIVISION OF PROPERTY, LAWYER’S
FEES OR EXPENSES BEFORE A DIVORCE OR ANNULMENT IS GRANTED, YOU MAY LOSE
THE RIGHT TO CLAIM ANY OF THEM.

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 CANNOT AFFORD 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.

LANCASTER BAR ASSOCIATION
LAWYER REFERRAL SERVICE
TELEPHONE : 717 393-0737

CSHC Page 1 of 5 FORM 1

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IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

In Re: The marriage of :
:
___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

COMPLAINT UNDER SECTION 3301 (c or d)
OF THE DOMESTIC RELATIONS CODE

1. Plaintiff is ___________________, who currently resides at

_________________________________________, since ________________________.

2. Defendant is _________________, who currently resides at

______________________________________, since ________________________.

3. Plaintiff and/or Defendant has/have been a bona fide resident/residents in the

Commonwealth for at least six months immediately previous to the filing of this Complaint.

4. The Plaintiff and Defendant were married on ____________________, in

___________________________________.

5. There have been no prior actions of divorce or for annulment between the parties except

_____________________________________.

6. The marriage is irretrievably broken.

7. Plaintiff has been advised of the availability of counseling and the Plaintiff may have the

right to request that the Court require the parties to participate in counseling.

CSHC Page 2 of 5 FORM 1

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WHEREFORE, Plaintiff requests the Court to enter a decree of divorce.

DATED: ___________________________________
Plaintiff

CSHC Page 3 of 5 FORM 1

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VERIFICATION

I verify that the statements made in this Complaint in Divorce are true and correct. I understand

that false statements made herein are made subject to the penalties of 18 Pa. C.S. §4904 relating to

unsworn falsification to authorities.

DATED: ___________________________________
Plaintiff

CSHC Page 4 of 5 FORM 1

———————– Page 22———————–

IN T HE C O URT O F C O MMO N P LEA S O F LA NCA ST ER C O UNTY , PENNSY LVA N IA

PROTHONOTARY
C IVI L COVER SH EET

PLEA S E L IST NA MES A ND A DDRESS ES OF A DDITIONAL PA RTIES ON A S EPA RATE S HEET.
PA RTY Z IP CODE S A RE RE QUIRED & PA RTY I NFORMATION MUST MATCH THE P LEA DING

For Prothonotary use only:

DOCKET No: CI-
TY PE OF A CTION:

PA RTY I NFOR MATION

PLAINT IFF’S NAM E: DEFENDANT ‘S NAM E:

A DDRESS : ADDRESS :

T ELEPHO NE # : T ELEPHO NE # :

FILING ATT OR NEY/ F ILING PA RTY I NFOR MATION

FIRM:

FILING ATT O RNEY/PA RTY : A O PC (Atto rney ID ) #:

ADD RESS:

C ITY : STAT E: ZIP CO DE:

T ELEPHO NE #: E-MAI L:

FAX #:

S IGNAT URE:

PLEASE DO NOT STAPLE THE COVER SHEET TO THE PLEADING. IF AN EVENT NEEDS TO BE
SCHEDULED, A CAO SCHEDULING COVER SHEET MUST ALSO BE ATTACHED.

CSHC Page 5 of 5 FORM 1

———————– Page 23———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

AFFIDAVIT OF SERVICE

I,___________________, hereby depose and say that on this date, I personally served the

above-captioned Defendant, with a Complaint in Divorce and Notice to Defend and Claim Rights

with Notice of Availability of Counseling, by personally handing the same to him/her.

I verify that the statements made in this Affidavit are true and correct. I understand that

false statements herein are made subject to the penalties of 18 Pa. CS. §4904 relating to unsworn

falsification to authorities.

Dated: _______________ _____________________________

CSHC FORM 2(a)

———————– Page 24———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

ACCEPTANCE OF SERVICE

I,___________________, Defendant in the above-captioned action depose and say that on

this date, I hereby accept service of the Complaint in Divorce and Notice to Defend and Claim

Rights with Notice of Availability of Counseling.

I verify that the statements made in this Affidavit are true and correct. I understand that

false statements herein are made subject to the penalties of 18 Pa. CS. §4904 relating to unsworn

falsification to authorities.

Dated: _______________ _____________________________

CSHC FORM 2(B)

———————– Page 25———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

AFFIDAVIT OF SERVICE

COMMONWEALTH OF PENNSYLVANIA )
) SS:
COUNTY OF LANCASTER )

I, ____________________ (Plaintiff), being duly affirmed according to law, depose and says

that:

1. On _______________ (date), a copy of the Complaint in Divorce in the above-captioned

matter was mailed to the Defendant by Certified Mail, Return Receipt Requested, Deliver to Addressee

Only, at the Defendant’s last known address, as indicated on the attached mailing receipt.

2. That on _________________ (date), the Defendant received the aforesaid Divorce

Complaint and the mailing receipt and return receipt card evidencing the same are attached hereto and

made a part hereof.

Affirmed and subscribed )
)
before me this ____ day of ) ________________________
) Plaintiff
____________, 20__. )
)
____________________ )
Notary Public )
My Commission Expires:

CSHC Page 1 of 2 FORM 3

———————– Page 26———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

AFFIDAVIT OF SIGNATURE

COMMONWEALTH OF PENNSYLVANIA )
) SS:
COUNTY OF LANCASTER )

_______________ (Plaintiff), being duly affirmed according to law, deposes and says that he/she

has examined the signature on the Return Receipt of the Post Office Department signed by

____________________ (Defendant), and that he/she is familiar with the signature of the said

Defendant, and that the signature on that card is the signature of the said Defendant.

Affirmed and subscribed )
)
before me this ____ day ) _________________________
) Plaintiff
of ____________, 20__. )
)
_____________________ )
Notary Public

My Commission Expires:

CSHC Page 2 of 2 FORM 3

———————– Page 27———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

AFFIDAVIT OF CONSENT

1. A Complaint in Divorce under §3301(c) of the Divorce Code was filed on

_________________________.

2. The marriage of Plaintiff and Defendant is irretrievably broken and ninety days

have elapsed from the date of the filing and service of the Complaint.

3. I consent to the entry of a final decree of divorce after service of Notice of

Intention to Request Entry of the Decree.

I verify that the statements made in this 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.

Dated: __________________ ______________________________
Plaintiff

CSHC FORM 4(a)

———————– Page 28———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

AFFIDAVIT OF CONSENT

1. A Complaint in Divorce under §3301(c) of the Divorce Code was filed on

_________________________.

2. The marriage of Plaintiff and Defendant is irretrievably broken and ninety days

have elapsed from the date of the filing and service of the Complaint.

3. I consent to the entry of a final decree of divorce after service of Notice of

Intention to Request Entry of the Decree.

I verify that the statements made in this 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.

Dated: __________________ ______________________________
Defendant

CSHC FORM 4(b)

———————– Page 29———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE
UNDER §3301(c) OF THE DIVORCE CODE

1. I consent to the entry of a final decree of divorce without notice.

2. I understand that I may lose rights concerning alimony, division of property,

lawyer’s fees or expenses if I do not claim them before a divorce is granted.

3. I understand that I will not be divorced until a Divorce Decree is entered by the

Court and that a copy of the Decree will be sent to me immediately after it is filed with the

Prothonotary.

I verify that the statements made in this 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.

Dated: _________________ ________________________________
Plaintiff

CSHC FORM 5(a)

———————– Page 30———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE
UNDER §3301(c) OF THE DIVORCE CODE

1. I consent to the entry of a final decree of divorce without notice.

2. I understand that I may lose rights concerning alimony, division of property,

lawyer’s fees or expenses if I do not claim them before a divorce is granted.

3. I understand that I will not be divorced until a Divorce Decree is entered by the

Court and that a copy of the Decree will be sent to me immediately after it is filed with the

Prothonotary.

I verify that the statements made in this 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.

Dated: _________________ ________________________________
Defendant

CSHC FORM 5(b)

———————– Page 31———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

PRAECIPE TO TRANSMIT RECORD

To The Prothonotary:

Transmit the record, together with the following information, to the Court for entry of a divorce decree:

1. Ground for divorce: irretrievable breakdown under §3301(c)OR §3301(d) of the divorce
code.

2. Date and manner of service of the complaint: .

3. Complete either paragraph (a) or (b).
(a) Date of execution of the Affidavit of Consent required by §3301(c) of the Divorce Code:

by Plaintiff

by Defendant

(b)(1) Date of execution of the Affidavit required by §3301(d) of the Divorce Code:
;
(2) Date of service of the Affidavit upon the opposing party: .

4. Related claims pending: None.

5. Complete either (a) or (b).
(a) Date and manner of service of the notice of intention to file praecipe to transmit record, a
copy of which is attached. .

(b) Date Plaintiff’s Waiver of Notice in §3301(c) Divorce was filed with the Prothonotary:

Date Defendant’s Waiver of Notice in §3301(c) Divorce was filed with the Prothonotary:
.

_____________________________________
( )Plaintiff
( ) Defendant

CSHC FORM 6

———————– Page 32———————–

:
Plaintiff : PRAECIPE
:
In the Court of Common Pleas of Lancaster County
:
vs. :

:
: No. CI-
:
Defendant :

TO THE PROTHONOTARY:

This is to certify that on this date, a true and correct copy of the foregoing Praecipe to
Transmit the Record was served upon the Defendant by first class mail to the following:

_________________________
(Name of Defendant)
__________________________
(Address of Defendant)
__________________________

BY
Plaintiff

Date

CSHC FORM 7

———————– Page 33———————–

In the C ourt of C ommon Pleas
P laintiff of Lancaster County

No. CI-

vs. AFFIDAV IT T HA T T HE D EFEN DAN T IS
NOT IN THE M ILITARY SERVICE, PUR SUANT

TO ” SOLDIER S AND SA ILORS ” CIVIL RELIEF
D efendant ACT O F 1918, RE -ENACT ED 1940.

LAN CASTER CO UN TY , SS: B efore me, the undersigned authority, personally appeared

(P laintiff) W ho b eing duly sworn accord ing to law , doth d ep ose and say that

(D efendant) the D efendant is not in the M ilitary or N aval Service, ba sed on the following

facts: A ge o f Defendant ; Pre sent place o f emp loym ent

;Pre sent place o f Residence as o f the d ate o f this Affidavit.

ADDITIONAL FA CTS , IF ANY.

__________________________________________________
(Signature o f party filing this A ffidavit)

Sworn and subscribed to before me this ____ day of _________________________, 20___

__________________________________________________
N otary Pub lic

CSHC FORM 8

———————– Page 34———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

DIVORCE DECREE

AND NOW, this ___ day of ___________, 20___, it is Ordered and Decreed that

___________________, Plaintiff, and __________________, Defendant, are divorced from the

bonds of matrimony.

BY THE COURT:

_________________________
J.

CSHC FORM 9

———————– Page 35———————–

LANCASTER COUNTY
OFFICE OF THE PROTHONOTARY – COURT OF COMMON
PLEAS – CIVIL

COURTHOUSE
50 NORTH DUKE STREET
PO BOX 83480
LANCASTER, PA 17608-3480
717-299-8282
717-293-7210 (FAX)

KATHERINE WOOD-JACOBS
Prothonotary

LORI GROFF
Chief Deputy

DIVORCE INFORMATION SHEET

Pursuant to Act 2001-82, Short Vital Statistic Form are
not required effective January 1, 2002. However, the
Prothonotary is required to provide the following
Information, in lieu of the short Vital Statistics Form.

Please complete the appropriate information and file with
the Prothonotary:

Docket Number:

Plaintiff’s Name:

Defendant’s Name:

Years Married: ____(5; ____5-9; ____10-14;

____15-19; _____20-24; ____24-29

____30+

CSHC FORM 10

———————– Page 36———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION-LAW

___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

NOTICE

If you wish to deny any of the statements set forth in this Affidavit, you must file a

Counteraffidavit within twenty (20) days after this Affidavit has been served on you or the

statements will be admitted.

AFFIDAVIT UNDER
SECTION 3301(d) OF THE DOMESTIC RELATIONS CODE

The parties to this action separated on _____________________ and have continued to

live separate and apart for a period of at least two years.

1. The marriage is irretrievably broken.

2. I understand that I may lose rights concerning alimony, division of property,

lawyer’s fees or expenses if I do not claim them before a divorce is granted.

I verify that the statements made in this 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 Plaintiff/Defendant

CSHC FORM 11

———————– Page 37———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION-LAW

___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

CERTIFICATE OF SERVICE

The undersigned hereby certifies that on this date, a true and correct copy of the foregoing

Affidavit under §3301(D) of the Domestic Relations Code was served by first class mail to the

following:

_____________________________

_____________________________

______________________________

By:

_____________________________
Date: ________________ Plaintiff/Defendant

CSHC FORM 11A

———————– Page 38———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

NOTICE OF INTENTION TO REQUEST ENTRY OF
§3301(d) DIVORCE DECREE

You have been sued in an action for divorce. You have failed to answer the Complaint or
file a Counteraffidavit to the Plaintiff’s §3301(d) Affidavit. Therefore, on or after
____________________, the Plaintiff can request the court to enter a final decree in divorce.

If you do not file with the Prothonotary of the court an answer with your signature
notarized or verified or a Counteraffidavit by the above date, the court can enter a final decree in
divorce. Unless you have already filed with the court a written claim for economic relief, you
must do so by the above date or the court may grant the divorce and you will lose forever the
right to ask for economic relief. A COUNTERAFFIDAVIT WHICH YOU MAY FILE WITH
THE PROTHONOTARY OF THE COURT IS ATTACHED TO THIS NOTICE.

YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
OFFICE SET FORTH BELOW TO FIND OUR WHERE YOU CAN GET LEGAL HELP.

DISTRICT COURT ADMINISTRATION OFFICE
LANCASTER COUNTY COURTHOUSE
50 NORTH DUKE STREET
LANCASTER, PA 17602
(717) 299-8041

CSHC Page 1 of 4 FORM 12

———————– Page 39———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

DEFENDANT’S COUNTERAFFIDAVIT UNDER
SECTION 3301(d) OF THE DIVORCE CODE

1. Check either (a) or (b):

(a) I do not oppose the entry of a divorce decree.

(b) I oppose the entry of a divorce decree because:

(check either (i), (ii), or both)

(i) the parties to this action have not lived separate and apart for a

period of two (2) years.

(ii) the marriage is not irretrievably broken.

2. (a) I do not wish to claim any claims for economic relief. I understand that I

may lose rights concerning alimony, division of property, lawyers fees or

expenses if I do not claim them before a divorce is granted.

(b) I wish to claim economic relief which may include alimony, division of

property, lawyer’s fees or expenses or other important rights.

CSHC Page 2 of 4 FORM 12

———————– Page 40———————–

I understand that in addition to checking (b) above, I must also file all of my economic

claims with the Prothonotary in writing and serve them on the other party. If I fail to do so

before the date set forth on the Notice of Intention to Request Divorce Decree, the Divorce

Decree may be entered without further delay.

I verify that the statements made in this Counteraffidavit are true and correct. I

understand that false statements herein are made subject to the penalties of 18 Pa. C.S. Section

4904 relating to unsworn falsification to authorities.

Date: __________________________
Plaintiff/Defendant

NOTICE: If you do not wish to oppose the entry of a divorce
decree and you do not wish to make any claim for economic relief, you need not file this
Counteraffidavit.

CSHC Page 3 of 4 FORM 12

———————– Page 41———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

CERTIFICATE OF SERVICE

The undersigned hereby certifies that on this date, a true and correct copy of the foregoing

Notice of Intention to Request Entry of Divorce Decree and CounterAffidavit was served by first

class mail to the following:

_______________________
_______________________
_______________________

By: ____________________________
Plaintiff/Defendant

Date: ____________________

CSHC Page 4 of 4 FORM 12

———————– Page 42———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

In Re: The marriage of :
:
___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

NOTICE TO DEFEND AND CLAIM RIGHTS

You have been sued in court. If you wish to defend against the claims set forth in the following
pages, you must take prompt action. You are warned that if you fail to do so, the case may proceed
without you and a decree of divorce or annulment may be entered against you by the court. A judgment
may also be entered against you for any other claim or relief requested in these papers by the plaintiff.
You may lose money or property or other rights important to you, including custody or visitation of your
children.

When the ground for the divorce is indignities or irretrievable breakdown of the marriage, you
may request marriage counseling. A list of marriage counselors is available in the Office of the
Prothonotary at the Lancaster County Courthouse, 50 North Duke Street, 2nd floor, Lancaster,
Pennsylvania.

IF YOU DO NOT FILE A CLAIM FOR ALIMONY, DIVISION OF PROPERTY, LAWYER’S
FEES OR EXPENSES BEFORE A DIVORCE OR ANNULMENT IS GRANTED, YOU MAY LOSE
THE RIGHT TO CLAIM ANY OF THEM.

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 CANNOT AFFORD 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.

LANCASTER BAR ASSOCIATION
LAWYER REFERRAL SERVICE
TELEPHONE : 717 393-0737

CSHC Page 1 of 5 FORM 13

———————– Page 43———————–

IN THE COURT OF COMMON PLEAS OF LANCASTER COUNTY, PENNSYLVANIA
CIVIL ACTION – LAW

In Re: The marriage of :
:
___________________________ :
Plaintiff :
:
vs. : No. CI-
:
___________________________ :
Defendant :

COUNT NUMBER I -
COMPLAINT UNDER SECTION 3301 (c or d)
OF THE DOMESTIC RELATIONS CODE

1. Plaintiff is ___________________, who currently resides at

_________________________________________, since ________________________.

2. Defendant is _________________, who currently resides at

______________________________________, since ________________________.

3. Plaintiff and/or Defendant has/have been a bona fide resident/residents in the

Commonwealth for at least six months immediately previous to the filing of this Complaint.

4. The Plaintiff and Defendant were married on ____________________, in

___________________________________.

5. There have been no prior actions of divorce or for annulment between the parties except

_____________________________________.

6. The marriage is irretrievably broken.

7. Plaintiff has been advised of the availability of counseling and the Plaintiff may have the

right to request that the Court require the parties to participate in counseling.

CSHC Page 2 of 5 FORM 13

———————– Page 44———————–

8. Plaintiff requests the Court to enter a decree of divorce.

COUNT NUMBER II – ALIMONY PENDENTE LITE

Paragraphs 1 through 8 of Plaintiff’s Complaint are incorporated herein by reference as though

set forth in full.

9. Plaintiff lacks sufficient property to provide for her reasonable means and is unable to

support herself through appropriate employment.

10. Plaintiff requires reasonable support to adequately maintain herself in accordance with

the standard of living established in the marriage.

WHEREFORE, Plaintiff requests your Honorable Court to enter an award of reasonable

temporary alimony until final hearing.

DATED: ___________________________________
Plaintiff

CSHC Page 3 of 5 FORM 13

———————– Page 45———————–

VERIFICATION

I verify that the statements made in this Complaint in Divorce are true and correct. I understand

that false statements made herein are made subject to the penalties of 18 Pa. C.S. §4904 relating to

unsworn falsification to authorities.

DATED: ___________________________________
Plaintiff

CSHC Page 4 of 5 FORM 13

———————– Page 46———————–

IN T HE C O URT O F C O MMO N P LEA S O F LA NCA ST ER C O UNTY , PENNSY LVA N IA

PROTHONOTARY
C IVI L COVER SH EET

PLEA S E L IST NA MES A ND A DDRESS ES OF A DDITIONAL PA RTIES ON A S EPA RATE S HEET.
PA RTY Z IP CODE S A RE RE QUIRED & PA RTY I NFORMATION MUST MATCH THE P LEA DING

For Prothonotary use only:

DOCKET No: CI-
TY PE OF A CTION:

PA RTY I NFOR MATION

PLAINT IFF’S NAM E: DEFENDANT ‘S NAM E:

A DDRESS : ADDRESS :

T ELEPHO NE # : T ELEPHO NE # :

FILING ATT OR NEY/ F ILING PA RTY I NFOR MATION

FIRM:

FILING ATT O RNEY/PA RTY : A O PC (Atto rney ID ) #:

ADD RESS:

C ITY : STAT E: ZIP CO DE:

T ELEPHO NE #: E-MAI L:

FAX #:

S IGNAT URE:

PLEASE DO NOT STAPLE THE COVER SHEET TO THE PLEADING. IF AN EVENT NEEDS TO BE
SCHEDULED, A CAO SCHEDULING COVER SHEET MUST ALSO BE ATTACHED.

CSHC Page 5 of 5 FORM 13

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