IN THE COURT OF COMMON PLEAS OF LEHIGH COUNTY, PENNSYLVANIA

CIVIL / FAMILY DIVISION

)	NO. -FC-
Plaintiff	)
vs	)	CUSTODY
)
Defendant	)

COUNTER-AFFIDAVIT REGARDING RELOCATION

I,	, received a Notice of Proposed
Relocation from	on	.
This proposal of relocation involves the following child/children:
Child’s Initials	Present

Residence	Age and Year of Birth
AGREEMENT OR OBJECTION (check all that apply)
1.	I do not object to the relocation.
2.	I do not object to the modification of the custody order consistent with the proposal for modification set forth in the notice.
3.	I do not object to the relocation, but I do object to modification of the custody order.
4.	I plan to request that a hearing be scheduled by filing a request for hearing with the court:
a.	Prior to allowing the child/children to relocate.
b.	After the child/children relocate.
5.	I do object to the relocation.
6.	I do object to the modification of the custody order.

I understand that in addition to objecting to the relocation or modification of the custody order above, I must also file this notice with the court in writing and serve it on the other party by certified mail, return receipt requested, addressee only, or pursuant to Pa.R.C.P. No. 1930.4, and, if there is an existing custody case, I must file this counter-affidavit with the court. If I fail to do so within 30 days of my receipt of the proposed relocation notice, I understand that I will not be able to object to the relocation at a later time.

I verify that the statements made in this counter affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Sec. 4904 relating to unsworn falsification to authorities.

Date	Signature

CERTIFICATE OF COMPLIANCE

I certify that this filing complies with the provisions of the Public Access Policy of the Unified Judicial System of Pennsylvania: Case Records of the Appellate and Trial Courts that require filing confidential information and documents differently than non-confidential information and documents.

Submitted by:
Signature:
Name:
Attorney No. (if applicable):

Rachel A Wotring

2019-10-29

County of Lehigh