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ARREST/CONVICTION REPORT ADID CtrRTIX'ICATION FORM

(under Act24 of2011 andAct82 of2012)

.Section l. Per.soll:rl llrlfirnrafiolr

Full Legal e: rl-ln., Jo.e Er.--h \ler!&e. \er E

Other na bv
Dateof Birth, Q6 ,Ls,)jsL
which you h ,e
been identi l:

Section 2. ,.\r'r'est or'('olrr iction

king this box, I state that I have NOT been arrested for or convicted of any Reportable Offense.

x king this box, I report that I have bee,n rrested for or convicted of an offense or offenses enumerated under
S.$$l-111(e)or(f.l)('ReportableOffense(s)'). SeePage 3ofthisFormforalistofReportableOffenses.

l)ct:rils of -\r'rcsts or' ('olrr ictiolts

For each arrest for or convistion ofany Reportable Offense, specifi in the space below (or on
additional attachments if necessary) the offense for which you have been arrested or convicted, the
date and location of arrest and/or conviction, docket number, md the applicable court

Section 3. ( hikl ,\buse

king this box, I state that I have NOT been named as a perpetrator of a founded rcport of child
within the past five (5) years as defined by the Child Protective Senrices Law.

u
hecking this box, I report thd I have been named as a p€rpetrator ofa founded report ofchild abuse within the
five (5) years as defined by the Child Protestive Services Law.

Section {. ( ertificiltion

By signing 'hisfonn I certifu under penalty of law that the stdtements nwde in thisform are true, correct and complete. I
thatfalse statements herein, ircluding, without limltatio4 anyfailure to accurately rcport @ty ffirest or coroictionfor a
Reportable Offense, shall subject me to criminal prosecation under l8 Pa.C.S. $49A4, relating to unswomfalsiy'ication to
authoriti,

lo - lq-Lo I
Signature Date

PDE-6004 0310112016
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INSTRUCTIONS

to 24 P.S. $1-11l(c.a) and 0), the Pennsylvania Deparunent of Education dweloped this standardized form
4) to be used by current and prrcspective employees of public and private schools, intermediate units, and
cational-technical schools.

uirdd by subsection (c.4) and $)Q) of 2a P.S. $ l - 1 I 1, this form strall be completed and submitted by all
and prospective employees ofsaid institutions to provide written reporting of any arrest or conviction for an
edumerated under 24 P.S. $$l-11l(e) and (f.l) and to provide notification of having been named as a
of a formded report of child abuse within the past five (5 ) years a defined by the Child Protective
ces Law.

ired by subsection (i)(a) of

24 P.S. $ I -1 1 1, this form also shall be utilized by orrent and prospective
yees to provide uniften notice
within seventy-two (72) hours alter a subsequent arrest or conviction for an
enumerated under 24 P.S. $$1-111(e) or (f,l).

with 24 P.S. $l-11I, employees completing this form are required to submit the form to the
nistrator or other person lEsponsible for employment decisions in a school entity. Please contact a supervisor
e school entity administration office with any questions regarding the PDE 6004, including to whom the form
ld be sent.

,YIDE ALL INT'ORMATION REQI]IRED BY TIIIS F'ORM LEGIBLY IN IhIIC

PDE-6004 03t0U2016
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LIST OT' REPORTABLE OF'T'ENSES

reportable offense enumereted under 24 P.S. $1-111(e) conslsts ofany ofthc following:

l) An offense under one or more of the following povisions of Tifle 1E ofthe Pennsylvania C"onsolidated
Statutes:

I Chapter 25 (relating to criminal lmmicide) Section 4304 (relating to endangering

r Section 27AZ (relating to aggravated assault) welfare of childrrcn)
I Section 27A9.1 (relating to stalking) Section 4305 (relating to dealing in infant
I Section 29Al (relating to kidnapping) children)
I Section 2902 (relating to unla$-1fuI restraint) A felony offense under section 5902(b)
t Section 2910 (relating to luring a child into a motor (relating to prostitution and related
vehicle or structure) offenses)
I Section 3l2l (relating to rape) Section 5903(c) or (d) (relating to obscene
I Section 3122.1 (relating to statutory sexual assaul0 and other sexual materials and
r Sestion 3123 (relating to involturtary deviate sexual performances)
intercourse) Section 6301(axl) (relating to coffuption
I Section 3124.1 (relating to sexual assault) of minors)
r Section 3124.2 (relating to institutional sexual assault) Section 6312 (relating to sexual abuse of
r Section 3lZs(relating to aggravated indecent assault) children)
I Section 3126 (relating to indecent assault) Section 6318 (relating to unlawful contact
r Section 3127 (relating to indecent exposure) with minor)
I Section 3129 (relating to sexual intercourse with animal) Section 6319 (relating to solicitation of
I Section 43AZ (relating to incest) minors to traffrc drugs)
I Section 4303 (relating to concealing death of child) Section 6320 (relating to sexual
exploitation of children)
(2) An offense designated as a felony under the act of April 14,1972 (P.L.233, No, 64), known as
'The Oontnolled Substance, Drug, Device and Cosmetio Act."

(3) An offense SIMILAR IN NATURE to those crimes listed above in clauses (l) and (2) under the
laws or former laws of:
.
the United States; or
.
one of its territories or possessions; or
.
another state; or
.
the District of Columbia; or
.
the Commonwealth of Puerto Rico; or
. a foreigt nation; or
. under a former law of this Commonwealth.

A reporteble olfense cn -mcrated under 24 P.S. $1-1U(f.1) eonsists of any of thc following:

(1) An offense graded as a felony oftnse of the first, second or third degree, otlrer than one of the
offenses enumerated under 24 P.S. $1-1 ll(e), ifless than (10) tcrr years has elapsed from the date
of expiration of the sentencp for the offense.

(2) An offense graded as a misdemeanor of the first degree, other than one of the offenses enumerated
rnder 24 P.S. g1-111(e), if less than (5) five years has elapsed from the date of expiration of the
s€ntence for tJre offense.

(3) An offense under 75 PaC.S. $ j802(a), O), (c) or (d)(relating to driving under influence of
alcohol or controlled substance) gaded as a midemeanor of the first degree under 75 PaC.S. $
3803 (relating to grading), if the person has been previously convicted of such an offense and less
than (3) three years has elapsed fiom the date of expiration of the sentence for the most rece,nt
offense.

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