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IN THE DISTRICT COURT OF ______________ COUNTY, KANSAS

____________________, Plaintiff vs. ____________________, Defendant PETITION FOR PROTECTIVE ORDER (Pursuant to K.S.A. 60-3101, et seq.) Case No. _______________

1. I live in the City of _________________, in the County of __________________, Kansas. 2. I have filed __________ (give number) petitions for protection from abuse in the past twelve months. The dates of these petitions are _________________________________. These petitions were filed in the counties of ________________________________________. (State which petitions, if any, involved abuse of a minor child) _______________________________. 3. I am seeking protection for: (check all that apply) _____ myself _____ my minor children (under age 18) _____ minor children who live with me 4. The defendant and I: (answer all that apply if you are asking for protection for yourself) _____ are currently in a dating relationship _____ were formerly in a dating relationship _____ currently live together in the same residence _____ formerly lived together in the same residence _____ have never lived together in the same residence _____ have had a child in common (If you are alleging that you and the defendant are or were in a dating relationship, briefly describe that relationship, including date the relationship ended, if appropriate):

The residence is: (answer if you want the judge to order the defendant to move) _____ a) jointly owned, or rented and jointly occupied by defendant and me _____ b) owned, or rented by me _____ c) owned, or rented by defendant only _____ d) owned, or rented by someone else (explain) _______________________________ ____________________________________________________________________ _____ e) none of the above (explain) ____________________________________________ ____________________________________________________________________ _____ f) not applicable because the defendant and I do not live together.

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5. The minor child(ren): (check all that apply if you are asking for protection for minor child(ren)) _____ is currently in a dating relationship with the defendant _____ was formerly in a dating relationship with the defendant ) _____ currently lives with the defendant (and has since the following date: _____ currently lives with me (and has since the following date: ) _____ formerly lived with the defendant _____ has never lived with the defendant _____ has had a child in common with the defendant (If you are alleging that the minor child and the defendant are or were in a dating relationship, briefly describe that relationship):

6. The following legal actions have been filed between me and the defendant or involving the minor children: (check case type, give county filed in, and give case number and date filed, if known) _____ divorce/custody _____ paternity _____ child in need of care _____ action seeking protective order _____ other 7. The following minor children are involved in this matter: (give full names and ages) Name DOB Mother's Name Father's Name

If you are requesting custody of a minor child who is also a child of the defendant, you must complete and attach an additional form concerning jurisdiction (UCCJEA form). 8. I am seeking protection from abuse because the defendant, _______________________ __________________ (name of person you are seeking protection from) has: (check all that apply) _____ _____ _____ _____ _____ caused me bodily injury or attempted to cause me bodily injury placed me in fear of imminent bodily injury by threatening me caused the minor children bodily injury or attempted to cause them bodily injury placed the minor children in fear of imminent bodily injury engaged in any of the following acts with a minor under 16 years of age who is not the spouse of the defendant: sexual intercourse or lewd fondling or touching of the person of either the minor or the defendant

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9.

The acts complained of occurred on these dates:

10. Briefly describe the specific facts about why you are seeking a protection from abuse order:

11. The defendant can be found at: (give all available addresses) HOME: street city ______________________ state ______________ zip code phone number _______________________________________________________ times when defendant is usually there street city ______________________ state ______________ zip code phone number _______________________________________________________ times when defendant is usually there

WORK:

OTHER:

street city ______________________ state ______________ zip code phone number _______________________________________________________ times when defendant is usually there

WHEREFORE, plaintiff requests that the Court issue an order of protection restraining defendant from: _____ _____ a) abusing, molesting or interfering with the privacy or rights of the plaintiff and the minor child(ren) b) entering or coming on or around the premises or the residence of the plaintiff located at:_________________________________________________________ (Give address or other description of residence from which defendant is to be excluded.)

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I am requesting that my ____ address and ____ telephone number remain confidential for the following reason: (complete if appropriate)

FURTHER, plaintiff requests that the Court also issue the following order(s): (check if appropriate) _____ c) defendant immediately move from and not return to the residence located at: ________________________________________________________ (You must include your address if defendant is ordered to be removed from the residence) _____ d) law enforcement officers be directed to evict the defendant from the residence located at: ____________________________________________ _____ e) law enforcement officers be directed to grant any assistance necessary to protect plaintiff and child(ren) from abuse Plaintiff further requests that copies of orders be given to the appropriate law enforcement agencies; that the Court issue an ex parte order of temporary custody of the minor child(ren), if appropriate; that a date, time and place for a hearing on this matter be set; and that summons be issued to defendant, notifying the defendant of this action and the relief requested. Plaintiff further requests that upon hearing of this cause, the Court issue a final order of protection, enjoining defendant from any acts of abuse against the plaintiff and the plaintiff's child(ren), and that the Court award to plaintiff the following additional relief: _____ a) suitable alternative housing for plaintiff and minor child(ren) _____ b) custody of the minor child(ren) (UCCJEA form completed) _____ c) child support _____ d) support of spouse _____ e) possession of personal property, and the assistance of a law enforcement officer in securing that property, if necessary _____ f) attorney's fees, if represented by counsel; and costs _____ g) counseling for defendant _____ h) other, please specify: __________________________________________________________________ and for such other and further relief, all as appropriate and as the Court deems necessary. __________________________________________ Plaintiff's signature

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(If attorney represents the plaintiff, the attorney's address and phone number must be provided.) ___________________________ ___________________________ ___________________________ VERIFICATION STATE OF KANSAS COUNTY OF __________ ) ) )

ss:

_____________________________, of lawful age, being first duly sworn states that (she)(he) is the plaintiff in the above action; that (she)(he) has read the foregoing Petition and knows the contents of it and that the declarations in it are true and correct to the best of plaintiff's knowledge and belief. __________________________________________ Plaintiff's signature

SIGNED AND SWORN to (or affirmed) before me on this _____ day of _______________, ______.

__________________________________________ Clerk of the District Court/Notary Public My Appointment Expires: ___________________

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