IN THE DISTRICT COURT OF ______________ COUNTY, KANSAS
____________________, Plaintiff vs. ____________________, Defendant Case No. _______________
COUNTER PETITION FOR PROTECTIVE ORDER (Pursuant to K.S.A. 60-3101, et seq.)
1. I live in the City of _________________, in the County of __________________, Kansas. 2. I have filed __________ (give number) petitions for protection from abuse in the past twelve months. The dates of these petitions are _________________________________. These petitions were filed in the counties of ________________________________________. (State which petitions, if any, involved abuse of a minor child) _______________________________. 3. I am seeking protection for: (check all that apply) _____ myself _____ my minor children (under age 18) _____ minor children who live with me 4. The plaintiff and I: (answer all that apply if you are asking for protection for yourself) _____ are currently in a dating relationship _____ were formerly in a dating relationship _____ currently live together in the same residence _____ formerly lived together in the same residence _____ have never lived together in the same residence _____ have had a child in common (If you are alleging that you and the plaintiff are or were in a dating relationship, briefly describe that relationship, including date the relationship ended, if appropriate):
_____ _____ _____ _____ _____
The residence is: (answer if you want the judge to order the plaintiff to move) a) jointly owned, or rented and jointly occupied by plaintiff and me b) owned, or rented by me c) owned, or rented by plaintiff only d) owned, or rented by someone else (explain) e) none of the above (explain)
f) not applicable because the plaintiff and I do not live together.
5. The minor child(ren): (check all that apply if you are asking for protection for minor child(ren)) _____ is currently in a dating relationship with the plaintiff _____ was formerly in a dating relationship with the plaintiff _____ currently lives with the plaintiff (and has since the following date: ) _____ currently lives with me (and has since the following date: ) _____ formerly lived with the plaintiff _____ has never lived with the plaintiff _____ has had a child in common with the plaintiff (If you are alleging that the minor child and the plaintiff are or were in a dating relationship, briefly describe that relationship):
6. The following legal actions have been filed between me and the plaintiff or involving the minor children: (check case type, give county filed in, and give case number and date filed, if known) _____ divorce/custody _____ _____ paternity _____ child in need of care _____ action seeking protective order ______ _____ other ______ 7. The following minor children are involved in this matter: (give full names and ages) Name DOB Mother's Name Father's Name
If you are requesting custody of a minor child who is also a child of the plaintiff, you must complete and attach an additional form concerning jurisdiction (UCCJEA form). 8. I am seeking protection from abuse because the plaintiff, _______________________ __________________ (name of person you are seeking protection from) has: (check all that apply) _____ _____ _____ _____ _____ caused me bodily injury or attempted to cause me bodily injury placed me in fear of imminent bodily injury by threatening me caused the minor children bodily injury or attempted to cause them bodily injury placed the minor children in fear of imminent bodily injury engaged in any of the following acts with a minor under 16 years of age who is not the spouse of the plaintiff: sexual intercourse or lewd fondling or touching of the person of either the minor or the plaintiff
9. The acts complained of occurred on these dates:__________________________________
10. (Briefly describe the specific facts about why you are seeking a protection from abuse order):
WHEREFORE, defendant requests that the Court issue an order of protection restraining plaintiff from: _____ a) abusing, molesting or interfering with the privacy or rights of the defendant and the minor child(ren) _____ b) entering or coming on or around the premises or the residence of the defendant located at: __________________________________________ (Give address or other description of residence from which plaintiff is to be excluded.) I am requesting that my ____ address and ____ telephone number remain confidential for the following reason: (complete if appropriate)
FURTHER, defendant requests that the Court also issue the following order(s): (check if appropriate) _____ c) plaintiff immediately move from and not return to the residence located at: ________________________________________________________ (You must include your address if plaintiff is ordered to be removed from the residence) _____ d) law enforcement officers be directed to evict the plaintiff from the residence located at: ____________________________________________ _____ e) law enforcement officers be directed to grant any assistance necessary to protect defendant and child(ren) from abuse Defendant further requests that copies of orders be given to the appropriate law enforcement agencies; that a date, time and place for a hearing on this matter be set; and that summons be issued to plaintiff, notifying the plaintiff of this action and the relief requested.
Defendant further requests that upon hearing of this cause, the Court issue a final order of protection, enjoining plaintiff from any acts of abuse against the defendant and the defendant's child(ren), and that the Court award to defendant the following additional relief: _____ a) suitable alternative housing for defendant and minor child(ren) _____ b) custody of the minor child(ren) (UCCJEA form completed) _____ c) child support _____ d) support of spouse _____ e) possession of personal property, and the assistance of a law enforcement officer in securing that property, if necessary _____ f) attorney's fees, if represented by counsel; and costs _____ g) counseling for plaintiff _____ h) other, please specify: ________________________________________ __________________________________________________________ __________________________________________________________ and for such other and further relief, all as appropriate and as the Court deems necessary. _______________________________________ Defendant's signature (If attorney represents the defendant, the attorney's address and phone number must be provided.) ___________________________ ___________________________ ___________________________ VERIFICATION STATE OF KANSAS ) ) COUNTY OF ____________)
_____________________________, of lawful age, being first duly sworn states that (she)(he) is the defendant in the above action; that (she)(he) has read the foregoing Petition and knows the contents of it and that the declarations in it are true and correct to the best of defendant's knowledge and belief. __________________________________________ Defendant's signature SIGNED AND SWORN to (or affirmed) before me on this _____ day of _______________, ______. __________________________________________ Clerk of the District Court/Notary Public My Appointment Expires: ___________________