Free PETITION FOR AN ORDER FOR PROTECTION AND REQUEST FOR A HEARING--Filed on Behalf of a Child - Indiana

PO-0101

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

STATE OF INDIANA

) ) SS: COUNTY OF ___________ )

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

___________________________________________ Name of Minor Child, Petitioner ___________________________________________, By Child's Next Friend, (Your Name) vs. ___________________________________________, Respondent (Person to be Restrained)

) ) ) ) ) ) )

PETITION FOR AN ORDER FOR PROTECTION AND REQUEST FOR A HEARING--Filed on Behalf of a Child 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 a child. The child who needs protection is or has been a victim of domestic or family violence, a sex offense, or stalking, and I am that person's: ___ parent ___ guardian ___ other representative (describe:___________________________ _________________________________________________). What is the Respondent's relationship to the child who needs protection? a. The Respondent is a family or household member (check only the line which best applies): ___ the Respondent is, or used to be my spouse and the child lived with us; ___ the Respondent and I resided together in an intimate relationship and the child lived with us; ___ the Respondent is a parent of the child; ___ the Respondent is, or used to, date the child; ___ the Respondent is, or has been, engaged in a sexual relationship with the child; ___ the Respondent and the child who needs protection have a child in common; ___ the Respondent and the child are related by blood or adoption. The Respondent is the child's _________________________; ___ the Respondent and the child are, or used to be, related by marriage. The Respondent is the child's _________________________;

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PO-0101

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b. c. 3. 4.

___ the Respondent is, or used to be, the child's guardian; ___ the Respondent is, or used to be, the child's custodian; ___ the Respondent is, or used to be, the child's foster parent; ___ the child who needs protection is a minor child of someone in one of the types of relationships described above. ___the Respondent has committed stalking against the child who needs protection. ___the Respondent has committed a sex offense against the child who needs protection.

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.

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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. the child who needs protection lives in this county. _____ d. the Petitioner lives 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 the child who needs protection; ___ the Respondent threatened to cause physical harm to the child who needs

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PO-0101

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protection; ___ the Respondent did cause physical harm to the child who needs protection; ___ the Respondent placed the child who needs protection in fear of physical harm; ___ the Respondent caused the child who needs protection to involuntarily engage in sexual activity by force, threat of force, or duress; ___ the Respondent committed stalking against the child who needs protection; ___ the Respondent committed a sex offense against the child who needs protection. ___ 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. 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: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

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PO-0101

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

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 the child who needs protection; ___ Prohibit the Respondent from committing, or threatening to commit, acts of domestic or family violence, stalking, or sex offenses against the family or household members of the child who needs protection. Their names are: ___________________________________________________________ __________________________________________________________; ___ Prohibit the Respondent from harassing, annoying, telephoning, contacting, or directly or indirectly communicating with the child who needs protection; ___Order the Respondent to stay away from the child's 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 the family or household member(s) of the child, 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 the child's residence, which is located at: ______________________________________; ___ Order the Respondent to give the child 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 the child's safety and welfare and the safety and welfare of the child's family or household members: _________________________________________________________ _________________________________________________________

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PO-0101

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

_________________________________________________________ _________________________________________________________. 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; ___ Require that parenting time be supervised by a third party; ___ Deny the Respondent parenting time; ___ Order the Respondent to pay the Petitioner's or child`s attorney fees; ___ Order the Respondent to pay rent for the child's residence; ___ Order the Respondent to make payment on a mortgage for the child's residence; ___ Order the Respondent to pay support for the child, or for minor child(ren) in common with the child who needs protection; ___ Order the Respondent to reimburse the Petitioner and/or the child who needs protection for expenses related 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 the Petitioner or child has 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 for relief from the Court regarding any of the following: · evicting the Respondent from the child's home;

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PO-0101

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

· giving the child 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.)

DATE: _______________

_______________________________________ PETITIONER - Type or print name of child ______________________________________ Signature of child's next friend

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