IN THE COURT OF COMMON PLEAS ______________________________DAUPHIN COUNTY, PENNSYLVANIA
PLAINTIFF
vs.
NO. _____________________________
_____________________________
DEFENDANT
SELF-REPRESENTED PARTY ENTRY OF APPEARANCE
OR (check only one box)
[] This is NOT a new case and ____________________________________________________previously
(Name of Attorney)
represented me in this case. I have decided not to be represented by that attorney and direct the Prothonotary to remove that attorney as my counsel of record in this case.
I have provided a copy of this form to that attorney listed above at the following address:_________________________________
I am entering my appearance as a self-represented party (sign) ___________________________________
My attorney acknowledges his/her withdrawal as my attorney in this case.
(Attorney signature) ____________________________________________________, Esq.
[] I am a victim of abuse and the other party to this action was the abuser. My address is listed on the Confidential Information Form Abuse Victim Addendum filed along with this Self-Represented Party Entry of Appearance.
[] I am not an abuse victim and my address for the purpose of receiving all future pleadings and other legal notices is: ____________________________________________________________________. I
understand that this address will be the only address to which notices and pleadings in this case will be sent, and that I am responsible to regularly check my mail at this address to ensure that I do not miss important deadlines or proceedings.
[] I am a victim of abuse and the other party to this action was the abuser. My telephone number and email address are listed on the Confidential Information Form Abuse Victim Addendum filed along with this Self-Represented Party Entry of Appearance.
[] I am not the victim of abuse and my telephone number where I can be reached during normal business hours (8:00 a.m. 4:30 p.m. Monday Friday) is ______________________________________. My email address is _________________________.
[] I have provided a copy of this form to all other attorneys or other self-represented parties at the following addresses as listed below: (Use reverse side if you need more space)
Name______________________________ Address__________________________________________
Name______________________________ Address__________________________________________
[] I am a victim of abuse and the other party to this action was the abuser. I understand that I should only provide a copy of this form to all other attorneys or self-represented parties BUT THAT I SHOULD NOT PROVIDE A COPY OF THE CONFIDENTIAL INFORMATION FORM ABUSE VICTIM ADDENDUM TO ANYONE EXCEPT TO THE COURT BY FILING THAT FORM WITH THE APPROPRIATE FILING OFFICE (PROTHONOTARY OR DOMESTIC RELATIONS).
I verify that the statements made in this Entry of Appearance as a Self-Represented Party are true and correct. I understand that if I make false statements herein, that I am subject to the criminal penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities which could result in a fine and/or prison term.
__________________
Date
__________________
Signature (Your Signature)
CERTIFICATION
I, _______________________________, certify that this filing complies with the provisions of the Case Records Public Access Policy of the Unified Judicial System of Pennsylvania that require filing confidential information and documents differently than non-confidential information and documents.
______________
Date
__________________
Signature
Daup. Cnty. Pa. 1930.8