Free ______________________County, Colorado - Colorado

Municipal Court

County Court

District Court

Denver Juvenile

Denver Probate

_________________________________ County, Colorado Court Address:
_________________________________________________

Plaintiff/Petitioner: ___________________________________ Date of Birth: _______________________ v. Defendant/Respondent: ___________________________________ Date of Birth: ________________________ Attorney or Party Without Attorney (Name and Address):

COURT USE ONLY Case Number:_______________

Phone Number:________________ E-mail: __________________ FAX Number:__________________ Atty. Reg. #: __________________
The address of the Protected Person may be omitted from the written order of the Court, including the Register of actions.

Division _____ Courtroom _____

VERIFIED

COMPLAINT

MOTION FOR CIVIL PROTECTION ORDER

I, ____________________________________ (name of person) request this Court to issue a Civil Protection Order, and in support of this request state the following:

1. I am seeking this Civil Protection Order as a victim of the following: (Mark the applicable circumstances.)
Domestic Abuse (§13-14-101(2), C.R.S.) Stalking (§18-9-111(4) to (6), C.R.S.) Sexual Assault (§18-3-402(1), C.R.S.) Unlawful Sexual Contact (§18-3-404, C.R.S.) Abuse of the Elderly or an At-Risk Adult (§26-3.1-101(1), C.R.S.) Physical Assault, Threat or other situation.

2.

I reside or am employed in the County of _____________________, State of _________________, and _________________________________ (name of person) resides or is employed in the County of __________________, State of ________________. I know _________________________(name of

person) because: ________________________________________________________________________

3. The other Protected Persons are (list full name ,date of birth, sex, and race):
Full Name of Protected Person Date of Birth Sex Race Full Name of Protected Person Date of Birth Sex Race

I have completed and attached the form titled "Affidavit Regarding Children" JDF 404 as children are identified as Protected Persons above.

4.

a) The most recent incident that causes me to ask for a Civil Protection Order occurred on or about

_____________________ (date), at about ________(time), in _______________________ (County), when
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_____________________________ (name of person) did the following to me and/or the above named Protected Persons: Be specific: What was the threat or acts of violence? Where did this occur? Were the minor children or other Protected Persons present? Was a weapon involved?

b) The most serious incident that causes me to ask for a Civil Protection Order occurred on or about ___________________________(date), at about ________(time), in _____________________ (County), when __________________________________ (name of person) did the following to me and/or the above named Protected Persons: Be specific: What was the threat or acts of violence? Where did this occur? Were the minor children or other Protected Persons present? Was a weapon involved?

c) Any other past incidents of violence or threats? Be specific: What was the threat or acts of violence? Where did this occur? Were the minor children or other Protected Persons present? Was a weapon involved?

d) Are you aware of any other Protection Orders currently in effect against you or the other person? Yes No If Yes, please list any relevant information, such as the issuing Court, State, and date of the order: _______________________________________________________________________________________ _______________________________________________________________________________________

5. I believe that I and/or the other Protected Persons named in this action are in imminent danger from
__________________________________ (name of person): Harm to my/our life or health if he/she is not restrained as requested. Physical or emotional harm to my/our emotional health or welfare if he/she is not excluded from the family home or the home of another.

6.

I request that I be permitted to omit my address from this Verified Complaint/Motion for Civil Protection Order, because I fear that including my address will endanger me and/or the other Protected Persons.

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7. I request the following relief from the Court that __________________________________ (name of person):
a) Be ordered to refrain from attacking, beating, molesting, intimidating, and verbally harassing me, following me, threatening my life, or threatening me with serious bodily injury. Be ordered to have no contact at all with me or the other Protected Persons. or Be allowed only the following limited contact with me or the other Protected Persons: Be specific. __________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ c) Be excluded from my home at (address): If you checked section 6, do not provide your address. ________________________________________________________________________________ Be ordered to stay at least ________ yards from the following places. (address or description) If you checked section 6, do not provide your address. Home: __________________________________________________________________________ Work: Name: _________________________ Address: _________________________________ School: Name: _________________________ Address: ___________________________________ Other: __________________________________________________________________________ Be ordered to have no contact with the minor children and that I be awarded temporary care and control and interim decision-making responsibility for the children. or That I be awarded temporary care and control of the children and that the other person be given parenting time with the children and interim decision-making responsibility as follows: Be specific.

b)

d)

e)

f)

Other:

I swear or affirm under penalty of perjury that the information contained in this Verified Complaint/Motion for Civil Protection Order is true and correct. I understand that once a Civil Protection Order is issued it cannot be modified or dismissed by me or the other person without permission of the Court.

___________________________________________ Attorney, if applicable

___________________________________________ Plaintiff/Petitioner Defendant/Respondent

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Stop: If you checked box number 6, do not fill in your address and telephone number.

___________________________________________ Address ___________________________________________ ___________________________________________ Telephone Number

Subscribed and affirmed, or sworn to before me in the County of ______________________, State of ________________, this ___________ day of _______________, 20 _____.

My Commission Expires: ________________________

______________________________________
Notary Public/Deputy Clerk

Notice: Colorado Revised Statutes §13-14-102 identifies that a temporary injunction may be issued by the
Court and that upon personal service or upon waiver and acceptance of service by the Restrained Person, is to be in effect against the Restrained Person for a period determined to be appropriate by the Court. This injunction restrains the Restrained Person from: 1. Ceasing to make payments for mortgage or rent, insurance, utilities or related services, transportation, medical care, or child care when the Restrained Person has a prior existing duty or legal obligation for making such payments. 2. Transferring, encumbering, concealing, or in any way disposing of personal effects or real property, except in the usual course of business or for the necessities of life. The Restrained Person shall be required to account to the Court for all extraordinary expenditures made after the injunction is in effect. Any injunction issued shall not exceed 120 days after the issuance of the Permanent Civil Protection Order.

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