FILE NUMBER:_________________________ DATE:________________________
**** FILL IN ALL INFORMATION BELOW OR WRITE NOT APPLICABLE (N/A)****
****PETITIONER (YOU)**** Name: ________________________________ Alias/Maiden Name: ______________ Date of Birth:____________________ Race: ____________ M/F_________________ Home Address: _________________________________________________________ City/State/Zip: __________________________________________________________ Does the respondent know that you live here? YES NO Workplace: ____________________________________________________________ Address: _______________________________________________________________ City/State/Zip: __________________________________________________________ Does the respondent know you work here? YES NO Other (school/daycare):__________________________________________________ Address: _______________________________________________________________ City/State/Zip: __________________________________________________________ Does the respondent know this address? YES NO Would you like the respondent to be ordered a distance of one block away from your residence/workplace/other? YES NO Does the Respondent live or work within a one city block radius of the above-listed addresses? YES NO Home phone: ______________ Work phone: _____________ Other: ______________ Does the respondent know these phone numbers? YES NO Can we leave a voice message on them? YES NO ****RESPONDENT(S) (OTHER PERSON/S)**** Name: ________________________________________________________________
What is your relationship to the respondent? _______________________ Date of marriage: ________ The respondent and I lived together from ____________________ to ___________________ What keys, if any, do you want removed from the respondent? ________________________________
****List minor children****
FULL LEGAL NAME
Date of Birth Male or Female (M/F) Race Is this your child? (Y/N) Is this your child with Respondent? (Y/N) Does this child currently live with you? (Y/N) Was the Recognition of Parentage signed? (Y/N/Not Sure) Paternity established through Court? (Y/N/Not Sure)
Rev 1/07 S:DA/Forms/Front Desk/RC Petitioners Information Sheet Page 1 of 2
CHECK ALL THAT APPLY: The respondent has inflicted or threatened domestic abuse upon the petitioner The respondent has inflicted or threatened domestic abuse upon the minor child(ren) If yes, name the child/ren who were victim/s:___________________________________ Would you like the respondent to have no contact with you in any way? Would you like the respondent to have no contact with the minor child/ren? Are you asking for custody of the child/ren? Would you like the respondent to have parenting time/visitation with the children? · If yes, would you like the parenting time/visitation to be: Supervised at a Children's Safety Center (see brochure)? YES NO Exchanged at a Children's Safety Center (see brochure)? YES NO Arranged or supervised by a third party? YES NO If so, by whom? _____________________________ Is this person aware of this? YES YES YES YES YES YES NO NO NO NO NO NO
The respondent and I have been involved in the following court proceedings: CHECK ALL THAT APPLY
CASE TYPE Is there a Final Ct Order Establishing Custody, Parenting Time, Child Support? COUNTY FILE NUMBER DATE/S FILED
ORDER FOR PROTECTION HARASSMENT RESTRAINING ORDER CHILD SUPPORT PATERNITY DISSOLUTION (DIVORCE) CHILD PROTECTION CRIMINAL PROCEEDINGS OTHER: _____________________________________
Which would you prefer (check appropriate box) : to obtain a one year order without a hearing today (and without the relief below) and ask for the relief below if the respondent requests a hearing.
request a hearing to address the relief below? **BE ADVISED THAT A HEARING IS REQUIRED TO ORDER THE RELIEF BELOW**
Would you like the respondent to be ordered to treatment/programming for domestic abuse? YES NO Would you like the respondent to be ordered to treatment/programming for chemical use? YES NO Would you like the respondent to be prohibited from acquiring or possessing a firearm? YES NO Would you like this order to be enforced in another state? YES NO ARE YOU SEEKING: Child support YES NO Spousal maintenance YES NO Medical support/health insurance YES NO My or the childs (ren's) health/dental insurance is provided by PETITIONER RESPONDENT If you are seeking child support or maintenance, please fill out this section: My income is $_______ per month, from _______________(source). I have monthly expenses of $________, including $________ for minor child (ren). Respondent's income is $__________ per month, from ______________ (source). I have childcare costs of $ _____________________ per month because of employment or school.
Rev 1/07 S:DA/Forms/Front Desk/RC Petitioners Information Sheet Page 2 of 2