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CRIMINAL RECORD / ABUSE HISTORY VERIFICATION
I___________ , hereby swear or affirm, subject to penalties of law including 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities that:
Check all that apply | Crime | Self | Other household member | Date of conviction, guilty plea, no contest plea or pending charges | Sentence |
[] | 18 Pa.C.S. Ch. 25 (relating to criminal homicide) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 2702 (relating to aggravated assault) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 2706 (relating to terroristic threats) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 2709.1 (relating to stalking) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 2901 (relating to kidnapping) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 2902 (relating to unlawful restraint) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 2903 (relating to false imprisonment) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 2910 (relating to luring a child into a motor vehicle or structure) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 3121 (relating to rape) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 3122.1 (relating to statutory sexual assault) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 3123 (relating to involuntary deviate sexual intercourse) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 3124.1 (relating to sexual assault) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 3125 (relating to aggravated indecent assault) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 3126 (relating to indecent assault) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 3127 (relating to indecent exposure) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 3129 (relating to sexual intercourse with animal) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 3130 (relating to conduct relating to sex offenders) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 3301 (relating to arson and related offenses) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 4302 (relating to incest) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 4303 (relating to concealing death of child) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 4304 (relating to endangering welfare of children) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 4305 (relating to dealing in infant children) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 5902(b) (relating to prostitution and related offenses) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 5903(c) or (d) (relating to obscene and other sexual materials and performances) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 6301 (relating to corruption of minors) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 6312 (relating to sexual abuse of children) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 6318 (relating to unlawful contact with minor) | [] | [] | ________ | ________ |
[] | 18 Pa.C.S. § 6320 (relating to sexual exploitation of children) | [] | [] | ________ | ________ |
[] | 23 Pa.C.S. § 6114 (relating to contempt for violation of protection order or agreement) | [] | [] | ________ | ________ |
[] | Driving under the influence of drugs or alcohol | [] | [] | ________ | ________ |
[] | Manufacture, sale, delivery, holding, offering for sale or possession of any controlled substance or other drug or device | [] | [] | ________ | ________ |
Checkall thatapply | Self | Other householdmember | Date | |
[] | A finding of abuse by a Children & Youth Agency or similar agency in Pennsylvania or similar statute in another jurisdiction | [] | [] | ________ |
[] | Abusive conduct as defined under the Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction | [] | [] | ________ |
[] | Involvement with a Children & Youth Agency or similar agency in Pennsylvania or another jurisdiction.Where?: | [] | [] | ________ |
[] | Other: | [] | [] | ________ |
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I verify that the information above is true and correct to the best of my knowledge, information or belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities.
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Signature
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Printed Name
231 Pa. Code § 1915.3-2