State of Minnesota
Judicial District: Court File Number: Case Type: Domestic Abuse
In the Matter of:
Petitioner (first, middle, last) vs.
Petitioner's Affidavit and Petition for Order for Protection (Minn. Stat. § 518B.01)
Respondent (first, middle, last) READ THE INSTRUCTIONS BEFORE FILLING OUT THESE FORMS. STATE OF MINNESOTA ) ) COUNTY OF _________________)
(County where Affidavit signed)
I, being sworn/affirmed on oath, state that: 1. I am the Petitioner (the person requesting the order) in this action. This affidavit supports my request for an Order for Protection (OFP). (Minn. Stat. § 518B.01).
2. A. My address is (Note: You may provide your address separately if you want it to be confidential.) . My date of birth is B. I am a female male and my race is (This information is necessary for Federal reporting requirements.) 3. .
A. Respondent's address is , and date of birth is . (If Respondent is under 18 years old, service must be made on parent or guardian of Respondent, as well as Respondent.) B. Respondent is a female male and his/her race is (This information is necessary for Federal reporting requirements.) .
My relationship with the Respondent(s) is as follows (check all that apply): Husband/Wife (date of marriage ) ) Former husband/wife (date of marriage Living together Lived Together (from ____/____/____ to ____/____/____) Have a child together Have an unborn child together Parent/child Related by blood
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Significant romantic or sexual relationship (if checked, answer items below): How long did the relationship last? How often did you have contact with Respondent? Length of time since the relationship ended: 5. I am (or have been) involved with the Respondent in the following court actions: Type of action Marriage dissolution/divorce Custody Paternity Domestic abuse related charges Domestic abuse related convictions Child protection County Date
For an explanation of what constitutes domestic abuse, see page 1 of the instructions. 6. I have / have not been involved with the Respondent in a prior application for an order for protection. (If you have been involved in a prior application for an order for protection, fill in the following): a. County where application was filed: b. Date filed: c. Name of Judge or judicial officer: d. Result: Temporary Ex Parte Order only (petitioner withdrew application or failed to appear) OFP granted; expiration date: OFP denied e. The following acts of abuse, harassment, or stalking have happened since I last applied:
Respondent has inflicted or threatened domestic abuse named here:
upon me and/or
upon the minor child(ren)
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Describe specific acts of domestic abuse and give approximate dates, listing the most recent incidents first. Attach additional sheets if necessary. (See paragraph 8 of the instruction sheet).
As a result of the domestic abuse, I have: (Attach any medical or police records to this Affidavit or bring them with you to court.) had contact with law enforcement sought medical help (Indicate dates and location if possible.)
Respondent and I are the parents of the following joint minor child(ren) (A joint minor child is a child born to you and the Respondent or adopted by you and the Respondent):
Name(s) Gender Date(s) of birth Person who child (ren) are with now Race Court Action involving child (ren)? (Indicate county/type)
/ / / / / 11. Other minor child (ren) who are involved:
Name(s) Gender Date(s) of birth Person who child (ren) are with now Race Your relationship to child (ren)
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Custody of the joint minor child(ren) listed below should be awarded to me.
Respondent should have the following parenting time (visitation) with the joint minor child(ren).
Respondent's parenting time (visitation) with the joint minor child(ren) should be supervised.
d. I am seeking the above relief because:
Additional Information: a. I am seeking child support / spousal maintenance / medical support/health insurance. (If you are seeking child support or maintenance, please fill out this section.) My income is $ per month, from , including $ (source). I have monthly expenses of $ child(ren). Respondent's income is $ per month, from (source). Address of Respondent's employer:
for joint minor
b. I have childcare costs of $ c. My or
per month because of employment or school. .
the child(ren's) health insurance is provided by
d. Other information:
As a result of the respondent's acts of domestic abuse, I am seeking restitution in the amount of for the following expenses: $
(See paragraph 14 of the instruction sheet.)
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Requests for Court Action
15. 16. An emergency exists and I fear immediate and present danger of further acts of domestic violence. Based on this affidavit, I am asking the court to issue an Ex Parte Order for Protection that gives me the following immediate protection and: Restrain and enjoin Respondent from causing me or the minor child(ren) any physical harm, and from causing me or the minor child(ren) fear of immediate physical harm. Order Respondent to have no contact with me or the minor child(ren), whether in person, with or through other persons, by telephone, mail, e-mail, through electronic devices, or through a third party, or by any other means. Exclude Respondent from: the dwelling we share. the place where I live: Address: the place where I work: Name Address: Petitioner's address is confidential . .
Order Respondent to continue all currently available insurance coverage without change in coverage or beneficiaries Other:
I do not request a hearing. I understand that the court may decline my request for an Ex Parte Order or the Respondent may request a hearing. OR I request a hearing. (If you wish to have the Respondent prohibited from acquiring or possessing a firearm, a hearing must be held.)
Based on this affidavit and any additional information before the court after a full hearing, I request the following, in addition to those items requested above: (If you request any of the following, a hearing will be held.) Exclude Respondent from a reasonable area surrounding my residence. Grant me sole legal and physical custody of the joint minor child(ren), subject to the following parenting time (visitation) to the Respondent (see question 12): No parenting time (visitation) Supervised parenting time (visitation) Parenting time (visitation) subject to the following conditions:
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Order Respondent to pay a reasonable amount of money for the support of our joint minor child(ren). Order Respondent to pay a reasonable amount of money for maintenance for me. Award me temporary use and possession of personal property and restrain respondent from disposing of or destroying property. Restitution in the amount of $ . (See question 14)
Direct that the following counseling, treatment, or other social services be provided to Respondent: Domestic Abuse program Alcohol/chemical dependency evaluation and treatment Other
Direct the local law enforcement agency to provide the following assistance:
Provide other relief as necessary for the protection of me and the minor child (ren).
I further request such other relief at the time of the full hearing as the Court finds necessary for the protection of a family or household member, including orders or directives to law enforcement agencies.
Signature (Sign only in front of notary public or court administrator.)
(If your address is confidential, provide the following ONLY on the Petitioner's Information Sheet.)
Subscribed and sworn to before me this day of , .
Address: City/State/Zip: Telephone:
Notary Public \ Deputy Court Administrator
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