Free DOMESTIC VIOLENCE PETITION FOR TEMPORARY EMERGENCY ORDER (TEPO) (SCA-DV-M-1230) - West Virginia

IN THE MAGISTRATE COURT OF
IN THE MATTER OF: First Middle Last v. First
Magistrate Court Case No.

COUNTY, WEST VIRGINIA
Middle Last

Petitioner

Respondent

Law Enforcement Completed Service Verification on Page 4

Yes

No

Family Court Civil Action No. (Same as Divorce, Separate Maintenance, Annulment Case No.)

DOMESTIC VIOLENCE PETITION for TEMPORARY EMERGENCY PROTECTIVE (TEPO) ORDER

The Respondent and I are parties to an action for divorce, separate maintenance or annulment in which a temporary order was entered in the family court of in (Civil Action No.) THE ACTS OF VIOLENCE OR ABUSE WHICH I OUTLINE IN THIS PETITION OCCURRED AFTER A TEMPORARY ORDER WAS ENTERED IN THE ACTION FOR DIVORCE, SEPARATE MAINTENANCE OR ANNULMENT WAS ENTERED. Therefore, pursuant to W. Va. Code § 48-27-402, I hereby request that the magistrate court issue a temporary emergency order to protect me and/or my minor children named herein from family violence or abuse. . County on (Date) and

NOTICE GIVEN TO REPSONDENT (check one): I attempted to notify Respondent of the PETITION as follows:

I did not attempt to notify Respondent of this PETITION because I fear for my safety and/or

FACTS ABOUT THE DOMESTIC VIOLENCE OR ABUSE (check each item that applies and insert information as requested if doing so will not endanger you or your children):

a.

I have been abused or threatened with abuse by Respondent.

SCA-DV-M-1230-1 / 09-3-03

ORIGINAL RESPONDENT ­ COPY PETITIONER ­ COPY RETURN ­ COPY

DV Petition for Temporary Emergency PO (TEPO) ­ Page 2 of 4 Magistrate Court Case No.: Family Court Civil Action No.:

b.

Respondent has abused or threatened to abuse minor child(ren). List name(s), age(s), and address(es), if address different from Petitioner's: DO NOT list children's address(es) if you fear for their safety.

CHILD'S NAME

DATE OF BIRTH

ADDRESS
(If different from Petitioner's)

RELATIONSHIP TO PETITIONER

RELATIONSHIP TO RESPONDENT

1. 2. 3. 4. PLEASE LIST ADDITIONAL CHILDREN ON A SEPARATE PAGE During the last five years, If any of the children have lived at addresses other than their current address, use the following space to list where they lived, and for how long. If there is not enough room in the following space, use an additional sheet of paper. I have attached additional sheet(s). Child's Name Former Address Dates of Residence

ANSWER THE FOLLOWING QUESTIONS: Yes No Have you been a party, a witness, or are you aware of any other court proceeding, in any state, concerning the custody of the minor children listed above? Are you aware of any persons other than you or the Respondent in this case who has custody, claims any custodial right, concerning the minor children listed above? Is a divorce pending? If yes, County , State of

Yes

No

Yes

No

Yes

No

Is a temporary divorce order in effect at the time of this Petition?

SCA-DV-M-1230-2 / 09-3-03

ORIGINAL RESPONDENT ­ COPY PETITIONER ­ COPY RETURN - COPY

DV Petition for Temporary Emergency PO (TEPO) ­ Page 3 of 4 Magistrate Court Case No.: Family Court Civil Action No.:

Yes

No

Is a separate domestic violence order in effect? If yes, County . State of I am currently living temporarily or permanently in . State of The Respondent is currently living temporarily or permanently in . State of County,

Please Fill In

Please Fill In

County,

The abuse or threats of abuse occurred on or about at
(City/County)

, State of

.

Describe the abuse or threats of abuse that led you to file this PETITION

RELIEF REQUESTED: I request that the court issue a temporary emergency protective order and that the order contain the following relief: DISCRETIONARY RELIEF: I understand that the court may grant the following relief if I ask for it. (check all that you are requesting) Direct Respondent to refrain from abusing me and/or the other person(s) named in this PETITION. Direct Respondent not to enter any school, business or place of employment, where I or a family or household member may be, for the purpose of violating the temporary emergency protective order. Direct Respondent to refrain from contacting, telephoning, communicating with, harassing, or verbally abusing the petitioner. I also request the following because the facts show that minor children (child) are being abused by Respondent. Grant me temporary custody of (list name(s) of child(ren):

Make the following changes in visitation:

SCA-DV-M-1230-3 / 09-3-03

ORIGINAL RESPONDENT- COPY PETITIONER ­ COPY RETURN ­ COPY

DV Petition for Emergency PO (TEPO) ­ Page 4 of 4 Magistrate Court Case No.: Family Court Civil Action No.:

AFFIDAVIT STATE OF WEST VIRGINIA COUNTY OF , TO-WIT:

I, , on oath or affirmation, say that I am the Petitioner named in this PETITION and that the facts contained herein are true, except that where they are stated to be on information and belief, I believe them to be true.

Signature Taken, subscribed, and sworn or affirmed before me this day of ,20 .

Notary Public/Magistrate/Assistant/Magistrate Clerk My commission expires on .

SERVICE BY LAW ENFORCEMENT Served on Respondent by , at (Date) (Time)

in am/pm.

County, W. Va., on

(Return of Service to Circuit Clerk)

NOTICE TO PETITIONER: IF YOU CANNOT AFFORD THE COSTS OF THESE PROCEEDINGS, YOU MAY FILE A FEE WAIVER AFFIDAVIT. IF YOUR PETITION IS DENIED, YOU HAVE THE RIGHT TO FILE AN APPEAL AT THE CIRCUIT CLERK'S OFFICE, USING SCA-DV-FC/M-1210. THIS MUST BE FILED WITHIN 5 DAYS OF THE DATE YOUR PETITION WAS DENIED.

SCA-DV-M-1230-4 / 09-3-03

ORIGINAL RESPONDENT ­ COPY PETIONER ­ COPY RETURN ­ COPY