Free PETITION FOR AN ORDER FOR PROTECTION AND REQUEST FOR A HEARING--Filed by Person Seeking Protection - Indiana

PO-0100

Approved 07-01-02 Revised 07-01-09

STATE OF INDIANA

) ) SS: COUNTY OF ___________ )

IN THE ______________ COURT_____ (____________DIVISION, ROOM ____) CASE NO. __________________________

________________________________________, Petitioner (Your Name) vs. ________________________________________, Respondent (Person to be Restrained)

) ) ) ) )

PETITION FOR AN ORDER FOR PROTECTION AND REQUEST FOR A HEARING--Filed by Person Seeking Protection IMPORTANT: This is a public document and a copy of it will be placed in the Court's file. A copy may also be sent to the Respondent. (Check those which apply) 1. I am filing this Petition for myself: ___a. I am or have been a victim of domestic or family violence; ___b. I am or have been a victim of a sex offense; ___c. I am or have been a victim of stalking. 2. The Respondent's relationship to me is: a. the Respondent is my family or household member (check only the line which best applies): ___ the Respondent is, or used to be, my spouse; ___ the Respondent and I resided together in an intimate relationship; ___ the Respondent and I have a child in common; ___ the Respondent and I are dating, or have dated, each other; ___ the Respondent and I are, or have been, engaged in a sexual relationship; ___ the Respondent and I are related by blood or adoption. The Respondent is my _________________________; ___ the Respondent and I are, or used to be, related by marriage. The Respondent is my _________________________; ___ the Respondent is, or used to be, my guardian; ___ the Respondent is, or used to be, my ward; ___ the Respondent is, or used to be, my custodian; ___ the Respondent is, or used to be, my foster parent; or, ___ I am a minor child of a person in one of the types of relationships described above. ___the Respondent has committed stalking against me.

b.

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c. 3. 4.

___the Respondent has committed a sex offense against me.

How old is the Respondent? ________ years old. Please list all cases (divorce, protection orders, paternity, guardianship, criminal, juvenile, civil) involving the Respondent, yourself, or a child you have with the Respondent (attach additional sheets of paper if necessary): Case Name Case Number County & State __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ _____ Continued on Attachment 4a.

5.

This case is filed in this county because: _____ a. the Respondent lives in this county. _____ b. the incident(s) of domestic or family violence, stalking, or the sex offense happened in this county. _____ c. I live in this county.

6.

If you are not represented by an attorney, fill in your public mailing address: __________________________________________________________________ __________________________________________________________________ This address will not be kept secret, so you should use a mailing address that you feel comfortable having public. If you want information on how to use the Attorney General's Address Confidentiality Program, call that office at: 1-800321-1907 to get information on how to participate in that program. The Respondent has committed the following act(s) of domestic or family violence, stalking, or a sex offense (check those which apply): ___ the Respondent attempted to cause physical harm to me; ___ the Respondent threatened to cause physical harm to me; ___ the Respondent did cause physical harm to me; ___ the Respondent placed me in fear of physical harm; ___ the Respondent caused me to involuntarily engage in sexual activity by force, threat of force, or duress; ___ the Respondent committed stalking against me; ___ the Respondent committed a sex offense against me; ___ the Respondent committed an act of animal cruelty by beating, torturing, mutilating, or killing a vertebrate animal without justification with an intent to threaten, intimidate, coerce, harass or terrorize a family or household member.

7.

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8.

Describe what happened in each of the above incidents including the date(s), place(s) and witnesses to each incident (attach additional sheets of paper if necessary): Date of Incident #1: ______________ Place of Incident: __________________________________________________ Description of Incident: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ List the names of all of the people who were present during the incident. You must include your own name if you were present: __________________________________________________________________ __________________________________________________________________ Date of Incident #2: ______________ Place of Incident: __________________________ Description of Incident: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ List the names of all of the people who were present during the incident. You must include your own name if you were present: __________________________________________________________________ __________________________________________________________________ Date of Incident #3: ______________ Place of Incident: __________________________ Description of Incident: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ List the names of all of the people who were present during the incident. You must include your own name if you were present: __________________________________________________________________ __________________________________________________________________ _____ Continued on Attachment 8a.

9.

I am asking the Court to order the following relief (check all which apply): ___ Prohibit the Respondent from committing, or threatening to commit, acts of domestic or family violence, stalking, or sex offenses against me; ___ Prohibit the Respondent from committing, or threatening to commit, acts of

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PO-0100

Approved 07-01-02 Revised 07-01-09

domestic or family violence, stalking, or sex offenses against my family or household members, whose names are: ___________________________________________________________ __________________________________________________________; ___ Prohibit the Respondent from harassing, annoying, telephoning, contacting, or directly or indirectly communicating with me; ___Order the Respondent to stay away from my residence, school, place of employment, or other place, which is the ___________, located at: _____________________________________________________________; ___Order the Respondent to stay away from the following location(s) frequented by my family or household member(s), which may include a residence, school, or place of employment: __________________________________ _____________________________________________________________ _____________________________________________________________; NOTE: The following requested relief may be granted immediately by the Judge, but the Court must hold a hearing within thirty (30) days: ___ Evict the Respondent from my residence, which is located at: _____________________________________________________________; ___ Order the Respondent to give me the possession and use of the following: ___The residence located at: ______________________________________; ___An automobile/other motor vehicle described as: ___________________ __________________________________________________________; ___ Other necessary personal items, described as: _____________________ __________________________________________________________ __________________________________________________________; ___Order the following additional relief necessary to provide for my safety and welfare and the safety and welfare of my family or household members: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________. NOTE: The following requested relief may be granted ONLY after notice to the Respondent and at a hearing to be held within thirty (30) days: ___ Specify the arrangements for parenting time with our minor child(ren); ___ Require that parenting time be supervised by a third party; ___ Deny the Respondent parenting time; ___ Order the Respondent to pay my attorney fees; ___ Order the Respondent to pay rent for my residence; ___ Order the Respondent to make payment on a mortgage for my residence; ___ Order the Respondent to pay child support for our minor child(ren); ___ Order the Respondent to pay support/maintenance for me; ___ Order the Respondent to reimburse me for expenses related

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to the domestic or family violence, stalking, or sex offense as follows (specify the amount for each expense and bring documentation of the expense with you to Court for the Hearing): ___ Medical expenses: $_________________ ___ Counseling: $_________________ ___ Shelter: $_________________ ___ Repair or replacement of damaged property: $_________________ ___ Other costs or fees I have as a result of bringing this case: $_________________

___ Prohibit the Respondent from using or possessing a firearm, ammunition, or deadly weapon; ___ Order the Respondent to surrender the following firearm(s), ammunition, or deadly weapon(s) to a specified law enforcement agency (list each item below and attach an additional sheet of paper if necessary): ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________; _____ Continued on Attachment 9a. 10. Number of pages attached: _____

By filing this Petition, I am respectfully requesting that the Court immediately issue an Ex Parte Order for Protection. I understand that, if I have asked the Court for any of the following: · evicting the Respondent from my/our home; · giving me the possession of personal property; · establishing rules for child parenting time; · requiring the Respondent to pay fees, expenses, or child support; · forbidding the Respondent from possessing a firearm, ammunition, or a deadly weapon; or, · ordering the Respondent to surrender firearm(s), ammunition, or deadly weapons, I must also ask the Court to set a date for a Hearing within thirty (30) days of today's date. I understand that if a Hearing is set, and if I fail to appear for the Hearing, the Court may terminate the Ex Parte Order and dismiss the case.

I affirm, under the penalties for perjury, that the foregoing representations are true: a. on the basis of my own personal knowledge. b. on the basis that I have been informed and believe that the facts stated are true. (NOTE: If this Petition is made solely on the basis of Petitioner's information and belief, Petitioner must attach affidavits by one or more persons who have personal knowledge of the facts stated.)

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PO-0100

Approved 07-01-02 Revised 07-01-09

DATE: _______________

___________________________________ PETITIONER (Signature) ___________________________________ PETITIONER (Type or print name)

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