Step By Step Instructions For Filling Out Form 12 Page 2

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Sample Form 12 (Defendant’s Waiver of Notice of Intention to Request Entry of a Divorce
Decree Under Section 3301(c) of the Divorce Code)
JANE SMITH DOE
Pro Se
Attorney for Plaintiff
111 Any Street
Philadelphia, PA 1910X
______________________________________
JANE SMITH DOE,
:
COURT OF COMMON PLEAS
Plaintiff
PHILADELPHIA COUNTY
:
FAMILY DIVISION
vs.
:
January TERM, 2006
JOHN DOE,
Defendant
:
NO. 123X
WAIVER OF NOTICE OF INTENTION
TO REQUEST ENTRY OF A DIVORCE DECREE
UNDER SECTION 3301(c) OF THE DIVORCE CODE
1. I consent to the entry of a final decree in divorce without further 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.
Date: _____________________
_________________________
(a) JOHN DOE, Defendant
43

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