Free Domestic Violence Petition / Motion - Kentucky

AOC-275.1 Doc.Code:COM Rev.3-09 Page1of3 CommonwealthofKentucky CourtofJustice www.courts.ky.gov KRSChapter403

CaseNo.

DOMESTIC VIOLENCE PETITION / MOTION

Court_______________________ County





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PETITIONER VS. RESPONDENT







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Information about Respondent: CurrentResidence:__________________________________________________________________________________ __________________________________________________________________________________________________ UsualResidence:__________________________________________________________________________________ __________________________________________________________________________________________________ Occupation:__________________________________________________________________________________ EmployerName:___________________________________________________________________________________ EmployerAddress:__________________________________________________________________________________ __________________________________________________________________________________________________ Sex Race Birthdate Height Weight SSN Operator License # State CAUTION: []Weaponinvolved []Believedtobearmedanddangerous ThePartieshavea []custody []dissolutionactionpendingin_____________________CircuitCourt. []Petitioner,[]Petitioner,onbehalfofminorchild(ren)saysthaton_______________,2____,in_______________ County,Kentucky,theabove-namedRespondentengagedinact(s)ofdomesticviolenceandabuse,inthat*: _________________________________________________________________________________________________

_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________
Copies to:
CourtFile Petitioner Respondent(copy with blacked-out portion served with summons) LocalDepartmentofCommunityBasedServices,CHFS CourtClerkinCountyofPetitioner'susualresidence,ifdifferent Lawenforcementagency(ies)designatedforservice Lawenforcementagency/dispatchresponsibleforLINKentry

* If additional space is needed for the factual statement, type on a separate sheet of paper and attach to the Petition/Motion.

ENSURE ENTRIES IN BOXES ARE COMPLETE, ACCURATE AND LEGIBLE TO ALLOW PROMPT ENTRY INTO LINK IF ORDER OR SUMMONS ISSUES.

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AOC-275.1 Rev.3-09 Page2of3

CaseNo._________________

1. Information about Petitioner or initials of any minor family member on whose behalf Petition is filed: NAME:__________________________________________________________________________________________ Birthdate: Age:_________________

UsualResidence:_________________________________________________________________________________ ________________________________________________________________________________________________ Directionsforruralareas:___________________________________________________________________________ ____________________________________________________________Lengthofresidencethere:______________ CurrentResidence(if different from above):____________________________________________________________ ________________________________________________________________________________________________ Lengthofresidencethere:__________________________________________________________________________ Occupation:______________________________________________________________________________________ EmployerName:__________________________________________________________________________________ EmployerAddress:________________________________________________________________________________ ________________________________________________________________________________________________ Directionsforruralareas:___________________________________________________________________________ 2.Respondent's relationship to Petitioner: []spouse;[]formerspouse;[]unmarried,withchildincommon; []unmarried,currentlyorformerlylivingtogether;[]child;[]stepchild;[]parent;[]grandparent; []otherrelative(specify)__________________________________________________________________________ _________________________________________________________________________________________________ 3.If Respondent and Petitioner have minor children, complete the following: Parent is(check one box or both boxes): PET. / RESP. Child'sNameBirthdate(mm/dd/yyyy) [][](1)___________________________________________________________________________________ Child'sAddress:__________________________________________________________________________________ ________________________________________________________________________________________________ [] [] (2)___________________________________________________________________________________ Child'sAddress:__________________________________________________________________________________ ________________________________________________________________________________________________ [] [] (3)___________________________________________________________________________________ Child'sAddress:__________________________________________________________________________________ ________________________________________________________________________________________________ [] [] (4)___________________________________________________________________________________ Child'sAddress:__________________________________________________________________________________ ________________________________________________________________________________________________

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AOC-275.1 Rev.3-09 Page3of3

CaseNo._________________ MOTION FOR RELIEF

[]PetitionerOR[]Petitioner,onbehalfofminorchild(ren),requeststhattheCourt: (1) Issue an emergency protective orderbasedonthepresenceofanimmediateandpresentdangerofdomestic violenceandabuseto: []restrain Respondentfromcommittinganyfurtheractsofdomesticviolenceandabuse;and/or [] restrain RespondentfromanycontactorcommunicationwithPetitionerexceptasdirectedbytheCourt;and/or []restrain Respondentfromdisposingof,ordamaging,anypropertyoftheparties;and/or []direct Respondentto vacateresidencesharedbythepartieslocatedat(specify address): _____________________________________________________________________________________ _____________________________________________________________________________________; []grant temporary custodyofminorchild(ren); []awardtemporary child support inaccordancewithKYChildSupportGuidelines.Iwill,ifpossible,document incomeofbothparentsatthehearingbyproducingincometaxreturns,paystubsoremployerstatements. Ifeitherparentisself-employedIwill,ifpossible,producereceiptsandexpensestatements.Iunderstand Respondentwillalsobenotifiedbysummonstoproducethesedocuments. []grant other reliefwhichwouldassistinstoppingfurtherdomesticviolence(describe): _____________________________________________________________________________________

_____________________________________________________________________________________;and, (2) Cause a summons to be issued for Respondent,settingadate,timeandplaceforahearingtoconsiderall relieftowhichPetitionermaybeentitled,includingthosematterscontainedinparagraph(1)onthispageofthis motion,andasappropriate,mandatorycounselingforRespondentandotherreliefasmaybeauthorizedbystatute. Petitioner states the allegations contained herein are true on information and belief. ________________________________________________ Petitioner's / Movant's Signature

NOTICE: IF AN ORDER IS ISSUED WHICH SAYS NO CONTACT AND YOU DECIDE TO HAVE CONTACT WITH THE RESPONDENT WHILE THIS ORDER IS IN EFFECT, YOU MAY BE PLACING YOURSELF AT RISK. ADDITIONALLY, SUCH CONTACT MAY RESULT IN THE RESPONDENT BEING ARRESTED FOR VIOLATING THE ORDER. Subscribedandsworntobeforemeon_____________________,2_______. Date:_________________________,2_______. ________________________________________*Name ________________________________________Title
*Must be signed my circuit clerk or other individual authorized by Court to provide and verify emergency petitions.





EPO/Summons:[]Issued[]Deniedbecause:_______________________________________________



COURT ACTION:



__________________________________________________________________________________________ __________________________________________________________________________________________ Summons:[]Issued[]Deniedbecause:____________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________________ Date:_________________________,2_______. ________________________________________Judge

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AOC-275.1 Doc.Code:COM Rev.3-09 Page1of3 CommonwealthofKentucky CourtofJustice www.courts.ky.gov KRSChapter403

CaseNo.

DOMESTIC VIOLENCE PETITION / MOTION

Court_______________________ County 000





First


















Last

Middle











PETITIONER VS. RESPONDENT







First


















Last

Middle

Information about Respondent: CurrentResidence:__________________________________________________________________________________ __________________________________________________________________________________________________ UsualResidence:__________________________________________________________________________________ __________________________________________________________________________________________________ Occupation:__________________________________________________________________________________ EmployerName:___________________________________________________________________________________ EmployerAddress:__________________________________________________________________________________ __________________________________________________________________________________________________ Sex Race Birthdate Height Weight SSN Operator License # State CAUTION: []Weaponinvolved []Believedtobearmedanddangerous 000 ThePartieshavea []custody []dissolutionactionpendingin_____________________CircuitCourt. 000 []Petitioner,[]Petitioner,onbehalfofminorchild(ren)saysthaton_______________,2____,in_______________ County,Kentucky,theabove-namedRespondentengagedinact(s)ofdomesticviolenceandabuse,inthat*: _________________________________________________________________________________________________

_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________


Copies to:

CourtFile Petitioner Respondent(copy with blacked-out portion served with summons) LocalDepartmentofCommunityBasedServices,CHFS CourtClerkinCountyofPetitioner'susualresidence,ifdifferent Lawenforcementagency(ies)designatedforservice Lawenforcementagency/dispatchresponsibleforLINKentry

* If additional space is needed for the factual statement, type on a separate sheet of paper and attach to the Petition/Motion.

ENSURE ENTRIES IN BOXES ARE COMPLETE, ACCURATE AND LEGIBLE TO ALLOW PROMPT ENTRY INTO LINK IF ORDER OR SUMMONS ISSUES.

Print

Reset Form

AOC-275.1 Rev.3-09 Page2of3

CaseNo._________________

1. Information about Petitioner or initials of any minor family member on whose behalf Petition is filed: NAME:__________________________________________________________________________________________ Birthdate: Age:_________________

UsualResidence:_________________________________________________________________________________ ________________________________________________________________________________________________ Directionsforruralareas:___________________________________________________________________________ ____________________________________________________________Lengthofresidencethere:______________ CurrentResidence(if different from above):____________________________________________________________ ________________________________________________________________________________________________ Lengthofresidencethere:__________________________________________________________________________ Occupation:______________________________________________________________________________________ EmployerName:__________________________________________________________________________________ EmployerAddress:________________________________________________________________________________ ________________________________________________________________________________________________ Directionsforruralareas:___________________________________________________________________________ 2.Respondent's relationship to Petitioner: []spouse;[]formerspouse;[]unmarried,withchildincommon; []unmarried,currentlyorformerlylivingtogether;[]child;[]stepchild;[]parent;[]grandparent; []otherrelative(specify)__________________________________________________________________________ _________________________________________________________________________________________________ 3.If Respondent and Petitioner have minor children, complete the following: Parent is(check one box or both boxes): PET. / RESP. Child'sNameBirthdate(mm/dd/yyyy) [][](1)___________________________________________________________________________________ Child'sAddress:__________________________________________________________________________________ ________________________________________________________________________________________________ [] [] (2)___________________________________________________________________________________ Child'sAddress:__________________________________________________________________________________ ________________________________________________________________________________________________ [] [] (3)___________________________________________________________________________________ Child'sAddress:__________________________________________________________________________________ ________________________________________________________________________________________________ [] [] (4)___________________________________________________________________________________ Child'sAddress:__________________________________________________________________________________ ________________________________________________________________________________________________

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AOC-275.1 Rev.3-09 Page3of3

CaseNo._________________ MOTION FOR RELIEF

[]PetitionerOR[]Petitioner,onbehalfofminorchild(ren),requeststhattheCourt: (1) Issue an emergency protective orderbasedonthepresenceofanimmediateandpresentdangerofdomestic violenceandabuseto: []restrain Respondentfromcommittinganyfurtheractsofdomesticviolenceandabuse;and/or [] restrain RespondentfromanycontactorcommunicationwithPetitionerexceptasdirectedbytheCourt;and/or []restrain Respondentfromdisposingof,ordamaging,anypropertyoftheparties;and/or []direct Respondentto vacateresidencesharedbythepartieslocatedat(specify address): _____________________________________________________________________________________ _____________________________________________________________________________________; []grant temporary custodyofminorchild(ren); []awardtemporary child support inaccordancewithKYChildSupportGuidelines.Iwill,ifpossible,document incomeofbothparentsatthehearingbyproducingincometaxreturns,paystubsoremployerstatements. Ifeitherparentisself-employedIwill,ifpossible,producereceiptsandexpensestatements.Iunderstand Respondentwillalsobenotifiedbysummonstoproducethesedocuments. []grant other reliefwhichwouldassistinstoppingfurtherdomesticviolence(describe): _____________________________________________________________________________________

_____________________________________________________________________________________;and, (2) Cause a summons to be issued for Respondent,settingadate,timeandplaceforahearingtoconsiderall relieftowhichPetitionermaybeentitled,includingthosematterscontainedinparagraph(1)onthispageofthis motion,andasappropriate,mandatorycounselingforRespondentandotherreliefasmaybeauthorizedbystatute. Petitioner states the allegations contained herein are true on information and belief. ________________________________________________ Petitioner's / Movant's Signature

NOTICE: IF AN ORDER IS ISSUED WHICH SAYS NO CONTACT AND YOU DECIDE TO HAVE CONTACT WITH THE RESPONDENT WHILE THIS ORDER IS IN EFFECT, YOU MAY BE PLACING YOURSELF AT RISK. ADDITIONALLY, SUCH CONTACT MAY RESULT IN THE RESPONDENT BEING ARRESTED FOR VIOLATING THE ORDER. Subscribedandsworntobeforemeon_____________________,2_______. Date:_________________________,2_______. ________________________________________*Name ________________________________________Title
*Must be signed my circuit clerk or other individual authorized by Court to provide and verify emergency petitions.





EPO/Summons:[]Issued[]Deniedbecause:_______________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Summons:[]Issued[]Deniedbecause:____________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________________ Date:_________________________,2_______. ________________________________________Judge

COURT ACTION:




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