Free Petition for an Order for Protection on Behalf of a Family or Household Member - Hawaii

IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI`I

PETITION FOR AN ORDER FOR PROTECTION ON BEHALF OF A FAMILY OR HOUSEHOLD MEMBER

CASE NUMBER

FC-DA No.

Petitioner's name, address and telephone number:
PETITIONER,

on behalf of SUBJECT

vs.

and, Petitioner's Attorney's name, address and telephone number:

RESPONDENT.

I. 1. 2.

Petitioner alleges, under penalty of perjury, that: This Petition is made pursuant to Hawai`i Revised Statutes ("H.R.S.") Chapter 586 and H.R.S. section 134-7. I (Petitioner) am submitting this petition on behalf of the following family or household member who is:

G a minor; G an incapacitated adult.
Name (Subject): The Subject is:

G male G female

Year of Birth

The Subject of this Petition is my (for example, child, nephew, uncle, parent, etc.): The legal parents/guardians of the Subject are: 3. The Subject resides on the island of O#ahu.

If the Subject has been declared incapacitated and/or is the subject of a guardianship ordered by a court, please complete the following case information: Case name: Location of court: 4. Case number: Type of case:

The Subject of this Petition has the following relationship with the Respondent named above: length of their relationship: day(s) month(s) year(s) A. G they are married. B. G they were married, but are now divorced. C. G they are current or former reciprocal beneficiaries. D. G they are or were dating (romantic, courting, or engaged). E. G they are now living together. F. G they used to live together. G. G they are related by blood and Respondent is the Subject's H. G they have a child/children together.

Attachments: Temporary Restraining Order; Notice of Hearing (Revised 10/07)FC
Reprographics (11/07)

Reset Form

1F-P-754

1F-P-754

PETITION FOR AN ORDER FOR PROTECTION ON BEHALF OF A FAMILY OR HOUSEHOLD MEMBER (continued) Page 2

C ASE N U M BER

FC-DA No.

5. The Respondent has abused the Subject and/or the listed family/household member(s) as follows: A. FIRST INCIDENT OF ABUSE Respondent abused G Subject and/or on (date) by hit

G choke G force to have sex G grab G
briefly describe this incident:

G doing or G threatening to do this: G kick G slap G punch G push G shove G

other

This was:

G physical harm; G threat of imminent physical harm, bodily injury, assault; G extreme psychological abuse; G malicious property damage.

These children were in the home, were close by, or were present when the above incident occurred: B. MOST RECENT INCIDENT OF ABUSE (check here if same as above G ) Respondent abused G Subject and/or on (date) by

G choke G force to have sex G grab G hit
briefly describe this incident:

G doing or G threatening to do this: G kick G slap G punch G push G shove G

other

This was:

G physical harm; G threat of imminent physical harm, bodily injury, assault; G extreme psychological abuse; G malicious property damage.

These children were in the home, were close by, or were present when the above incident occurred:

C. OTHER INCIDENT(S) OF ABUSE (attach continuation page(s) if needed) Respondent abused G Subject and/or on (date) by hit

G choke G force to have sex G grab G
briefly describe this incident:

G doing or G threatening to do this: G kick G slap G punch G push G shove G

other

This was:

G physical harm; G threat of imminent physical harm, bodily injury, assault; G extreme psychological abuse; G malicious property damage.

These children were in the home, were close by, or were present when the above incident occurred:

1F-P-754

PETITION FOR AN ORDER FOR PROTECTION ON BEHALF OF A FAMILY OR HOUSEHOLD MEMBER (continued) Page 3
6.

C ASE N U M BER

FC-DA No.

The Respondent: A. G may be mentally ill. B. G may use illegal drugs. C. G is a member of the Armed Services G is deployed or has received deployment orders. D. G may need supervised visitation with the children because:

E.

G may own/possess/have access to a weapon (describe):

7.

Firearms (check all that apply and fill in the blanks): A. The Respondent:

G owns G possesses G has access to G intends to obtain G
1) Description of firearm(s):

intends to transfer ownership of

firearm(s), which may be used to threaten, injure or abuse a person as follows:

2) Location of firearm(s): (give street address and describe specific place where firearm is located)

B.

The Respondent is a member of the police department, a sheriff, a law enforcement officer, a member of the armed forces of the State of Hawai#i or the United States, a mail carrier, or is employed by the State, or subdivisions thereof, or the United States, and may be required to be armed while on duty. Other court cases: The Subject and/or my family and household members and/or the Respondent are or have been involved in other court cases (check all that apply and list the case number if you know it):

G

8.

9.

G Divorce G Restraining Order/Protective Order G Juvenile G Child Support G Others: The address I live in is G owned G rented by:

G Paternity G C.P.S. G Criminal

10. The social worker or police officer or other official from this agency told me to file this Petition (identify the agency):

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PETITION FOR AN ORDER FOR PROTECTION ON BEHALF OF A FAMILY OR HOUSEHOLD MEMBER (continued) Page 4

C ASE N U M BER

FC-DA No.

II. Based on the foregoing statements and information, Petitioner requests the following: 1. A Temporary Restraining Order enjoining the Respondent and any other person acting on the Respondent's behalf from: A. B. C.

G G G

contacting, threatening or physically abusing the Subject and the Subject's family and household members (no contact includes no meetings, email, phone calls, messaging, mail). entering or visiting the Subject's residence. contacting, threatening, or physically abusing the Subject at his/her place of work.

Employer's name and address:

D.

G contacting, threatening, or physically abusing the children at school.

School's name and address:

E. F. 2.

G maliciously/intentionally damaging the Subject's property or the property of the Subject's family and household members. G psychologically abusing the Subject and the Subject's family and household members.
An order requiring that Respondent immediately vacate the Subject's residence.

G

3. An order requiring Respondent to appear in court and show cause as to why the Order should not be continued. 4. A Protective Order continuing the Temporary Restraining Order and including:

G temporary visitation and custody orders. G temporary prohibition of visitation with (children's names):____________________________ __ __ __ ___________ __ __ __ __ G supervised visitation with (children's names):
to be supervised by: _______________________________ who:

G requiring the Respondent to participate in domestic violence intervention services and/or other counseling. G G
5. The Protective Order should last for at least month(s) or year(s).

G does not yet know of this request G has agreed to this

I HEREBY SOLEMNLY AND SINCERELY DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE HEREIN ARE TRUE AND CORRECT TO THE BEST OF MY BELIEF, INFORMATION, AND KNOWLEDGE.

Petitioner's Signature

Dated: Honolulu, Hawai`i,

.

1F-P-754

PETITION FOR AN ORDER FOR PROTECTION ON BEHALF OF A FAMILY OR HOUSEHOLD MEMBER (continued)
(court cases continuation sheet) Attach this page after page two of the petition . OTHER INCIDENT(S) OF ABUSE (attach continuation page(s) if needed) Respondent abused G the Subject and/or on (date) by hit

C ASE N U M BER

FC-DA No.

G choke G force to have sex G grab G
briefly describe this incident:

G doing or G threatening to do this: G kick G slap G punch G push G shove G

other

This was:

G physical harm; G extreme psychological abuse;

G threat of imminent physical harm, bodily injury, assault; G malicious property damage.

These children were in the home, were close by, or were present when the above incident occurred:

. OTHER INCIDENT(S) OF ABUSE (attach continuation page(s) if needed) Respondent abused G the Subject and/or on (date) by hit

G choke G force to have sex G grab G
briefly describe this incident:

G doing or G threatening to do this: G kick G slap G punch G push G shove G

other

This was:

G physical harm; G extreme psychological abuse;

G threat of imminent physical harm, bodily injury, assault; G malicious property damage.

These children were in the home, were close by, or were present when the above incident occurred:

. OTHER INCIDENT(S) OF ABUSE (attach continuation page(s) if needed) Respondent abused G the Subject and/or on (date) by hit

G choke G force to have sex G grab G
briefly describe this incident:

G doing or G threatening to do this: G kick G slap G punch G push G shove G

other

This was:

G physical harm; G extreme psychological abuse;

G threat of imminent physical harm, bodily injury, assault; G malicious property damage.

These children were in the home, were close by, or were present when the above incident occurred:

1F-P-754

LEGAL DEFINITIONS "Dating relationship" means a romantic, courtship, or engagement relationship, often but not necessarily characterized by actions of an intimate or sexual nature, but does not include a casual acquaintanceship or ordinary fraternization between persons in a business or social context. Pursuant to section 586-4(b) of the Hawai`i Revised Statutes ("HRS"), for any person who is alleged to be a family or household member by virtue of a dating relationship, the court may consider the following factors in determining whether a dating relationship exists: (1) The length of the relationship; (2) The nature of the relationship; and (3) The frequency of the interaction between the parties. "Domestic abuse" means: (1) Physical harm, bodily injury, assault, or the threat of imminent physical harm, bodily injury, or assault, extreme psychological abuse or malicious property damage between family or household members; or (2) Any act which would constitute an offense under HRS section 709-906, or under part V or VI of HRS chapter 707 committed against a minor family or household member by an adult family or household member. "Extreme psychological abuse" means an intentional or knowing course of conduct directed at an individual that seriously alarms or disturbs consistently or continually bothers the individual, and that serves no legitimate purpose; provided that such course of conduct would cause a reasonable person to suffer extreme emotional distress. "Family or household member" means spouses or reciprocal beneficiaries, former spouses or former reciprocal beneficiaries, persons who have a child in common, parents, children, persons related by consanguinity, persons jointly residing or formerly residing in the same dwelling unit, and persons who have or have had a dating relationship. "Malicious property damage" means an intentional or knowing damage to the property of another, without his consent, with an intent to thereby cause emotional distress.