Free AFFIDAVIT - RELIEF FROM ABUSE - Connecticut

AFFIDAVIT RELIEF FROM ABUSE
JD-FM-138 Rev. 5-06 C.G.S. §§ 46b-15, 52-231a, P.B. § 25-57

STATE OF CONNECTICUT SUPERIOR COURT
www.jud.ct.gov
INSTRUCTIONS TO APPLICANT (Affiant)

This affidavit must be completed and given to the clerk along with your completed Application for Relief From Abuse, form JD-FM-137. Your affidavit must include a statement of the conditions from which you seek relief and must be made under oath (you must swear that your statement is true and sign it in front of a court clerk, a notary public, or an attorney who will also sign and date the affidavit). The statement must be true to the best of your knowledge. Give recent, specific examples along with dates and state if any arrest was made related to the incidents outlined in this statement. If you seek temporary custody of your minor child(ren), you must also complete an Affidavit Concerning Children, form JD-FM-164.
NAME OF APPLICANT (Your name) NAME OF RESPONDENT (Person against whom application is filed) DOCKET NO. (For court use only)

STATEMENT OF CONDITIONS FROM WHICH YOU SEEK RELIEF I, the undersigned, duly depose and say that I am the Applicant in this matter and state as follows:

STATEMENT CONCERNING TEMPORARY CUSTODY OF CHILDREN "X" one of the following: I am not seeking temporary custody of any minor child(ren) in this matter. I am seeking temporary custody of my minor child(ren) in this matter. (Complete an Affidavit Concerning Children, form JD-FM-164, and bring it to the clerk along with this form and your completed Application For Relief From Abuse, form JD-FM-137.)
I hereby certify that the foregoing statements are true to the best of my knowledge and belief.
SIGNATURE PRINT NAME OF PERSON SIGNING DATE SIGNED

SUBSCRIBED AND SWORN TO BEFORE ME (Asst. Clerk, Comm. of Superior Court, Notary Public)

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