Free Petition For Protection From Domestic Violence/Child Abuse/Vulnerable Adult Abuse - Maryland

Judge Time Hours Minutes

CIRCUIT COURT

DISTRICT COURT OF MARYLAND FOR

City/County

Located at

Court Address

Case No.

(NOTE: Fill in the following, checking the appropriate boxes. Petitioners need not give an address if doing so risks further abuse or reveals the confidential address of a shelter. If this is the case, check here If you need additional paper, ask the clerk.)
Petitioner Street Address, Apt. No. City, State, Zip Code Home: Work: Telephone Number(s)

vs.

Respondent Street Address, Apt. No. City, State, Zip Code Home: Work: Telephone Number(s)

PETITION FOR PROTECTION FROM DOMESTIC VIOLENCE CHILD ABUSE VULNERABLE ADULT ABUSE
1. I want relief for myself minor child vulnerable adult, from abuse by The Respondent committed the following acts of abuse against on or about, slapping shoving other The details of what happened are: (Describe injuries. State when and where these acts occurred. Be as specific as you can.):
Date

(check all that apply.)

kicking

punching

choking/strangling stabbing stalking

shooting

rape or other sexual offense (or attempt) mental injury of a child

hitting with object detaining against will

threats of violence

2. (If the victim is a child or vulnerable adult, fill in the following): I am asking for protection for a vulnerable adult whose name is At this time the victim can be found at I am State's Attorney DSS a relative an adult living in the home. 3. The person(s) I want protected are (include yourself if you are a victim): Names(s) Birthdate

child

Relationship to Respondent

CC-DC/DV 1 (Rev. 4/2009)

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Case No.
Petitioner

vs.
Respondent

4. the person(s) I want protected now lives, or has lived, with the Respondent for the following period of time during the past year: There are are not additional persons living in the home. 5. I know of the following court cases involving me, or the person I want protected, and the Respondent. (Examples include: paternity, child support, divorce, custody, domestic violence, juvenile cases, criminal cases) Court Kind of Case Year Filed Result or Status (if you know)

6. Describe all past injuries the Respondent has caused the victim, and give date, if known

7. The Respondent owns or has access to the following firearms:

8. I want the court to order the Respondent: (NOTE: Petitioner need not give an address if doing so risks further abuse.) NOT to abuse or threaten to abuse
Name(s)

NOT to contact, attempt to contact, harass
Name(s)

NOT to go to the residence(s) at

Address

NOT to go to the school(s) at
Name of school and address

NOT to go to the child care provider(s)

Name of child care provider and address

NOT to go to the work place(s) at

Name(s)

To leave the home at and give possession of the home to The name(s) on the deed or lease are: To turn over firearm(s) to a law enforcement agency. To go to counseling domestic violence drug/alcohol

Address

other

To pay money as Emergency Family Maintenance (may be taken from Respondent's paycheck). CC-DC/DV 1 (Rev. 4/2009)
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Case No.
Petitioner

vs.
Respondent

9. I also want the Court to order: Custody of be granted to
Name Children's names

Use and possession of the following jointly-owned vehicle be granted to
Description of vehicle

Name

10. (Fill in only if you are seeking Emergency Family Maintenance.) The Respondent has the following financial resources: Income from employment in the amount of $ every week 2 weeks month other Source of employment income
Name and address of source and amount(s) received

Income from other source
Name and address of source and amount(s) received

The Respondent also owns the following property of value: Automobile(s) $
Estimated Value

Home $
Estimated Value

Bank Account(s) $
Estimated Value Estimated Value

Other:

I solemnly affirm under the penalties of perjury that the contents of the foregoing Petition are true to the best of my knowledge, information and belief.
Date Petitioner

I have filled in the Addendum (Description of Respondent), CC-DC/DV 1A NOTE If you believe that you have been a victim of abuse and that there is a danger of serious and immediate injury to you, you may request the assistance of a police officer or local law enforcement agency. The law enforcement officer must protect you from harm when responding to your request for assistance and may, if you ask, accompany you to the family home so that you may remove clothing and medicine, medical devices, and other personal effects required for you and your children, regardless of who paid for them. You are entitled to request that address and telephone number of a victim, a complainant, or a witness be considered for shielding at the filing of this application. NOTICE: Remote access to the name, address, telephone number, date of birth, e-mail address, and place of employment of a victim or non-party witness is blocked. (Md Rule 16-1008(a)(3)(B))

CC-DC/DV 1 (Rev. 4/2009)

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