Free Microsoft Word - HAR102 - Minnesota

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Judicial District: Court File Number: Case Type: Harassment

Petitioner's Affidavit and Petition for Harassment Restraining Order (Minn. Stat. §609.748)
Petitioner(s)
Your Name and Address

Respondent(s)
Name(s) and addresses of persons harassing you and/or your child (ren):

vs.

Date(s) of Birth: ___________________________

Date(s) of Birth: __________________________ (if known)

STATE OF MINNESOTA

) ) COUNTY OF _________________)
(County where Affidavit signed)

ss.

I understand that I am under oath/affirmation and that I must tell the truth and I state that: 1. I am (we are) the Petitioner(s) in this action. (I am) (My minor child (ren) is) (My minor ward(s) for whom I am the legal guardian is) the victim of harassment described in this petition. Our/My relationship to the respondent(s) is/are: 2. The following court cases involve the respondent and myself in issues regarding child custody or parenting time issues: Court File Number Court Jurisdiction

3. The following are specific acts of harassment committed by Respondent(s). (Check the boxes that apply and describe. Provide as many details as possible.) Respondent physically or sexually assaulted the Petitioner as follows:

HAR102

State

ENG

Rev 8/08

www.mncourts.gov/forms

Page 1 of 3

Respondent has followed, pursued or stalked the Petitioner as follows:

Respondent(s) made uninvited visits to the Petitioner(s) as follows:

Respondent(s) made harassing phone calls to the Petitioner(s) as follows:

Respondent(s) made threats to the Petitioner(s) as follows:

Respondent(s) frightened Petitioner(s) with threatening behavior as follows:

Respondent(s) called the Petitioner(s) abusive names as follows:

Respondent(s) damaged the Petitioner's property as follows:

Respondent(s) broke into and entered the Petitioner's residence as follows:

Respondent(s) stole property from the Petitioner(s) as follows:

Respondent(s) took pictures of the Petitioner(s) without permission of the Petitioner(s) as follows:

Other: 3. I ask the Court to issue a Restraining Order. I ask the Court to order the following: Respondent(s) shall not harass me my minor child (ren) or ward(s). List minor children/wards included in this Petition:

Respondent(s) shall have no contact with

me

my minor child (ren) or ward(s) listed above.

Respondent(s) shall stay away from where I/we live (address)

Respondent(s) shall stay away from my place of employment located at
HAR102 State ENG Rev 8/08 www.mncourts.gov/forms Page 2 of 3

. Other: 4. I request a court hearing I do not request a court hearing. I have been advised that the respondent may request a hearing. The court will notify me by mail at least five days before the hearing date.

Dated:
Signature (Sign only in front of notary public or court administrator.)

Name: Subscribed and sworn to before me Date:
Notary Public \ Deputy Court Administrator

Address: City/State/Zip: Telephone:

HAR102

State

ENG

Rev 8/08

www.mncourts.gov/forms

Page 3 of 3