Free APPLICATION FOR RELIEF FROM ABUSE - Connecticut


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Pages: 2
Date: August 11, 2008
File Format: PDF
State: Connecticut
Category: Court Forms - State
Author: RPansius
Word Count: 983 Words, 5,849 Characters
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URL

http://www.jud2.ct.gov/webforms/forms/fm137.pdf

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APPLICATION FOR RELIEF FROM ABUSE
JD-FM-137 Rev. 9-07 C.G.S. 29-28, 29-32, 29-33, 29-36k, 29-36i, 46b-15, 46b-38nn, 46b-38oo, 52-231a, 53a-217c, P.A. 07-78

STATE OF CONNECTICUT

SUPERIOR COURT
www.jud.ct.gov

INSTRUCTIONS TO APPLICANT

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1. Use a typewriter or print clearly in ink.You must also complete an Affidavit, form JD-FM-138. Give both forms to the Clerk of Court. 2. After your Application and Affidavit are processed, the clerk will give you the proper papers to have served on the Respondent. 3. Make sure the originals are returned to court after service. 1. If Ex Parte relief is ordered, prepare Restraining Order - Relief From Abuse, form JD-FM-139; be sure to check the Ex Parte Restraining Order box on page 1 and complete the Order and Notice of Court Hearing on page 2. 2. If Ex Parte relief is NOT ordered, prepare Order and Notice of Court Hearing - Relief From Abuse, form JD-FM-140. 3. Provide the Applicant with the original and one copy of the Application and Affidavit. Retain copies of each for court file. 4. Provide the Applicant with the Procedures For Relief From Abuse Process brochure JDP-FM-142 for further information. COURT LOCATION (No., street, town, zip code) DATE OF BIRTH (mm/dd/yyyy) (Town) (Town) (Town) SEX (M/F) DOCKET NO. RACE (State) (State) (State) (Zip Code) (Zip Code) (Zip Code)

INSTRUCTIONS TO CLERK

JUDICIAL DISTRICT OF NAME OF APPLICANT (Last, First, MI)

ADDRESS TO WHICH MAIL IS TO BE SENT (No., street) HOME/DWELLING ADDRESS* WORK ADDRESS* Same as mailing address

* NOTE: The home address and/or work address provided above will be included on any orders entered by the court. If you do not wish to provide your home address and/or work address, do not complete these boxes. However, failure to disclose your location information may limit the protection your can receive by the restraining order. If you believe that disclosure of location information would jeopardize you and/or your child(ren)'s health, safety or liberty, you may file a Request For Nondisclosure of Location Information with the Clerk of Court.

INFORMATION ABOUT THE RESPONDENT
NAME OF RESPONDENT (Person against whom application is filed) (Last, First, MI) ADDRESS OF RESPONDENT (No., street) RESPONDENT'S TELEPHONE NUMBER RESPONDENT IS ("X" all that apply) MY SPOUSE MY FORMER SPOUSE A PERSON WITH WHOM I HAVE A CIVIL UNION A PERSON WITH WHOM I HAD A CIVIL UNION PARENT OF MY CHILD MY PARENT MY CHILD A PERSON 18 OR OVER RELATED TO ME BY BLOOD OR MARRIAGE A PERSON 16 OR OVER WITH WHOM I RESIDE OR WITH WHOM I HAVE RESIDED A CARETAKER WHO IS PROVIDING SHELTER IN HIS OR HER RESIDENCE TO A PERSON 60 YEARS OF AGE OR OLDER A PERSON WITH WHOM I HAVE (OR RECENTLY HAD) A DATING RELATIONSHIP (Town) OTHER IDENTIFIERS (Examples include height, weight and approximate age) DATE OF BIRTH (mm/dd/yyyy) SEX (M/F) (State) RACE (Zip Code)

"X" here if you have cohabited with the Respondent as an intimate partner (romantic, spousal, or sexual relationship while living together).

"X" here if a Protective Order/Restraining Order exists affecting any party to this Application (Enter Docket No.and Court Location)
DOCKET NO. COURT LOCATION

"X" here if a dissolution of marriage (divorce), dissolution of civil union, custody or visitation action exists involving the same parties. (Enter Docket No.and Court Location)
DOCKET NO. COURT LOCATION

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NAME OF APPLICANT

NAME OF RESPONDENT

DOCKET NO.

APPLICATION FOR RELIEF FROM ABUSE
I have been subjected to a continuous threat of present physical pain or physical injury by the Respondent named above as stated more fully in my attached Affidavit. 1. I REQUEST THAT THE COURT ORDER THE FOLLOWING CONDITIONS: ("X" all that apply)
CT01 CT02 CT03 CT04 CT05 CT06 CT07 CT08

Respondent refrain from imposing any restraint upon my person or liberty. Respondent refrain from threatening, harassing, stalking, assaulting, molesting, sexually assaulting or attacking me. Respondent refrain from entering the family dwelling, my dwelling or wherever I shall reside. Respondent may return to the dwelling one time with police to retrieve belongings. Respondent refrain from having any contact in any manner with me. Respondent refrain from coming within 100 yards from me. Respondent refrain from entering my place of employment. That the order protect other persons:
NAME (Last, First, MI) DATE OF BIRTH(mm/dd/yyyy) RELATIONSHIP TO ME

CT09 CT10

That this order protect my minor children. Respondent refrain from entering the premises of the child(ren)'s school/day care. That this order protect animals owned or kept by me.
2. I REQUEST THAT THE COURT MAKE THE FOLLOWING TEMPORARY CHILD CUSTODY AND VISITATION ORDERS:

CT20

Award me temporary custody of the following minor child(ren) who is (are) also the child(ren) of the Respondent.
NAME (Last, First, MI) SEX (M/F) DATE OF BIRTH (mm/dd/yyyy) NAME (Last, First, MI) SEX (M/F) DATE OF BIRTH (mm/dd/yyyy)

1 2 3
CT21

4 5 6

With visitation as follows:

CT22

Without visitation rights to the Respondent.
3. I REQUEST THAT THE COURT ORDER THE FOLLOWING: (FURTHER ORDER)

REQUEST FOR EX PARTE (IMMEDIATE) RELIEF ("X" if applicable)
4. I REQUEST THAT THE COURT ORDER EX PARTE (IMMEDIATE) RELIEF BECAUSE I BELIEVE THERE IS AN IMMEDIATE AND PRESENT PHYSICAL DANGER TO ME AND/OR MY MINOR CHILDREN AND/OR ANIMALS OWNED OR KEPT BY ME.
SIGNED (Applicant)

X

Subscribed and sworn to before me:

SIGNED (Clerk, Notary, Comm. Sup. Ct )

DATE SIGNED

OPTIONAL TO APPLICANT (If you choose to answer, "X" the appropriate boxes below) 1. Does the respondent hold a permit to carry a pistol or revolver?................... 2. Does the respondent possess one or more firearms?...................................
YES YES NO NO UNKNOWN UNKNOWN

JD-FM-137 Rev. 9-07

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