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IN THE DISTRICT COURT OF ________________ COUNTY STATE OF OKLAHOMA Petitioner(s), vs. Defendant(s). ) ) ) ) ) ) )

Case No. PO-

PETITION FOR PROTECTIVE ORDER Petitioner, being sworn, states: 1. (Check one or more) The Defendant has caused or attempted to cause serious physical harm to The Defendant has threatened The Defendant has harassed The Defendant has stalked _______________________________. (If the petitioner is a victim of stalking, but is not a family or household member or an individual who is or has been in a dating relationship with the Defendant, the Petitioner must file a complaint against the Defendant with the proper law enforcement agency before filing a petition for a protective order with the District Court. The petitioner should be prepared to present a copy of the complaint to the court at the full hearing.) 2. The incident(s) which caused the filing of the petition occurred on or about (Dates) (Describe what happened)(Harassment requires a pattern of conduct. Stalking requires repeated following.)

(Attach additional sheet with more information, if necessary) 3. Was a weapon used in the incident? ______ If "yes" what kind of weapon? Are there weapons on the premises? If "yes" what kinds of weapons?

4. The Petitioner and additional parties are related to the Defendant as follows: (check all that apply) Married Parent & Child Persons Related by Marriage Persons Living Same Household Biological Parents Same Child Persons in a Dating Relationship Divorced Persons Related by Blood Present Spouse of an Ex-Spouse Formerly Living Same Household Persons in a Previous Dating Relationship Not Related (Stalking requires filing police complaint, with copy attached. No other relief is permitted by the Protection from Domestic Abuse Act for non-related parties.)

5. (Check and Complete A or B) A. Petitioner does not request an Emergency Ex Parte Order but requests the relief checked below after notice and hearing. B. Petitioner is in immediate and present danger of abuse from the Defendant and an Emergency Ex Parte Order is necessary to protect the Petitioner from serious harm. The Petitioner requests the following relief in the Ex Parte Order: (check one or more)

RELIEF REQUESTED Order Defendant to have no contact with Petitioner, either in person or by telephone, at any time or place. Order Defendant to not abuse, threaten, injure, assault, molest, stalk, harass, or otherwise interfere with Petitioner. Assume emergency jurisdiction under UCCJEA, and Order suspension of child visitation orders due to physical violence or threat of abuse by Defendant or a threat to violate a custody order by Defendant. Order Defendant to not stalk the Petitioner. Order Defendant to leave the residence located at _________________________________ on or before ____________________, and take no action to change utilities or telephone service. Order Law Enforcement Officers to accompany Defendant to the residence to remove necessary clothing and personal effects, and remain in attendance until Defendant leaves the premises. Order Defendant who is a minor, to leave the residence located at ________________________ by immediately placing Defendant in any type of care authorized for children taken into custody pursuant to 10 O.S. §7303-1.1a Circle Age of Minor Defendant: 13 14 15 16 17 Describe other relief Petitioner requests: ______________________________________________ 6. Petitioner is a resident of the county wherein this Petition is filed. Defendant is a resident of the county wherein this Petition is filed The domestic abuse occurred in the county wherein this Petition is filed, but neither Petitioner nor Defendant are residents of this county. 7. Petitioner requests that Defendant be ordered to pay all court costs, costs of service, photo evidence fees and attorneys' fees, if applicable. 8. WARNING: Whoever makes a statement or allegation in this Petition for Protective Order but does not believe that the statement or allegation is true, or knows that it is not true, or intends thereby to avoid or obstruct the ascertainment of the truth, may be found guilty of perjury. Pursuant to Sections 500 and 504 of Title 21 of the Oklahoma Statutes, the penalty for perjury, or subornation of perjury, is a felony punishable by imprisonment for not more than five (5) years. 9. Petitioner, being first duly sworn on oath states: I have read the above and foregoing document, understand the meaning thereof, and declare, under penalty of perjury, that the facts and statements contained herein are believed to the best of my knowledge to be the truth and nothing but the truth. I understand that I am required by Court Order to appear at the Hearing on my Petition. PETITIONER Subscribed and sworn to before me this ____ day of ___________, 20____. Deputy Court Clerk, Judge or Notary Defendant's Address(es) for Service Petitioner requests following law enforcement agencies receive copy of any protective Order entered herein:

If address is tribal land, which tribe? Official AOC Form (complies with Session Law Ch. 407, 49th Legislative Session effective 11/1/03)
AOC Form 68 Revised 9/07