Free SOUTH DAKOTA - All

STATE OF SOUTH DAKOTA COUNTY OF

) ) )

IN CIRCUIT COURT ________________ JUDICIAL CIRCUIT

Petitioner -vs, Respondent

TPO NO._____________________ PETITION AND AFFIDAVIT FOR A PROTECTION ORDER (STALKING, OR PHYSICAL INJURY AS A RESULT OF AN ASSAULT, OR A CRIME OF VIOLENCE)

I, __________________________________ the above named Petitioner, or the Parent/Legal Guardian of the minor child Petitioner, being duly sworn upon oath, state and affirm the following: I am a resident of County, South Dakota. The Respondent is a resident of County, South Dakota. I AM ASKING THE COURT FOR A PROTECTION ORDER BASED UPON THE FACTS BELOW: On or about (month) (day) (year) at approximately o'clock (am/pm), the person's acts of harassment seriously alarmed, annoyed, or harassed you (check all that apply): Willfully, maliciously, and repeatedly followed me. Harassed me by pursuing a knowing and willful course of conduct which seriously alarms, annoys or harasses me with no legitimate purpose. The pattern of conduct is a series of acts over a period of time, however short, showing a continuing pattern of harassment. Made a credible threat with the intent to place me in reasonable fear of death or great bodily injury. Willfully, maliciously, and repeatedly harassed me by means of any verbal, electronic, digital media, mechanical, telegraphic, or written communication. I, as the Petitioner, have suffered physical injury as a result of an assault. I, as the Petitioner, have been the victim of a crime of violence. Provide a detailed description of what happened on the above date:

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Form UJS-121A (Stalking Petition) Rev. 05/08

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Was law enforcement called for this incident? Was the person against whom you seek protection arrested for this incident? Is the person in jail? Has the person violated previous protection orders? If so, against whom_______________________________________ Give the date of the violation________________ and the county and state of the violation______________________________________ Has the person been found guilty of violating previous protection orders? If so, against whom_______________________________________ Give the date of the conviction________________ and the county and state of the conviction______________________________________ Does the person possess guns or weapons? Was a weapon used in this incident? Has the person threatened anyone with a weapon?

Provide a detailed description of other similar incidents or actions (please include dates and times, if possible):

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Form UJS-121A (Stalking Petition) Rev. 05/08

Continued from Page 2 _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

REQUEST FOR HEARING AND PROTECTION ORDER Based upon this Petition and Affidavit in which I truthfully set forth the details of the stalking, I respectfully ask the court to set a date to hear this matter and after hearing the evidence, to grant me a Protection Order: 1) To Restrain the Respondent from: a) following or harassing, or making any credible threat with the intent to place petitioner(s) in reasonable fear of death or great bodily injury, SDCL 22-19A-1; b) from causing any injury as a result of an assault or a crime of violence, SDCL 22-1-2(9). 2) To Grant the Protection Order for a period of time (no longer than 5 years). 3) To exclude the Respondent from the Petitioner's residence listed in 4C. 4) To Order that the Respondent shall not come within a distance of ___________ from the following persons and places: A. The Petitioner personally B. The following minor children named as other protected persons: Name Date of birth Relationship ___________________________ ___________ _______________________________ ___________________________ ___________ _______________________________ ___________________________ ___________ _______________________________ C. The Petitioner's residence (street/apt)___________________________________________ (city)__________________________________, (state) _______. (zip) ________ - ____ D. The Petitioners place employment (street)________________________________________ (city)_______________________________, (state)_______ (zip) _________-________ E. Other places (street/apt) (city) , (state)_______ (zip) (street/apt) (city) , (state)_______ (zip) (street/apt) (city) , (state)_______ (zip) 5) That the Respondent be restrained from contact with the Petitioner or other protected persons, by any direct or indirect means except as authorized by a court order. 6) To Order other relief which I believe is necessary for my protection:

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Form UJS-121A (Stalking Petition) Rev. 05/08

(If you are requesting an immediate temporary protection order without notice to the person you want restrained and without an opportunity for the person to appear; you must state why you believe you will suffer immediate and irreparable injury or damage if you have to wait until the hearing.) REQUEST FOR IMMEDIATE PROTECTION ORDER WITHOUT NOTICE TO THE OTHER PARTY I am not requesting an immediate Temporary Protection Order. In addition to what I have requested in sections 1-5 above, I further request that the Court grant me an immediate Temporary Protection Order Restraining Respondent from Stalking based upon the following sworn statements and beliefs: The reasons I need this order immediately and cannot wait until the scheduled hearing are:

_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ I believe that I will suffer immediate and irreparable injury, loss or damage if I am not granted an immediate Temporary Protection Order without notifying the Respondent and his/her attorney or giving the other party an opportunity to be heard. The immediate and irreparable injury, loss or damage which I believe I will suffer is:

_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ On this _____ day of _____________, ________, I swear or affirm under oath that the information I have provided in this Petition and Affidavit are true and correct to the best of my knowledge. I believe I am entitled to the protection I have requested. I am asking for this protection for valid reasons and am not attempting to harass the person I am seeking protection against and am not attempting to abuse or delay the court process or any other legal action.

Petitioner

Signed and sworn to before me on this

day of

,

(SEAL) Notary Public/Deputy Clerk of Courts Commission Expires: 4
Form UJS-121A (Stalking Petition) Rev. 05/08