IN THE CIRCUIT COURT OF BENTON COUNTY, ARKANSAS 1. 2. Petitioner’s Home Address: Petitioner Petitioner’s Workplace and Address: Date of Birth VS: Case No.: 3. 4. Respondent’s Home Address: Respondent Respondent’s Workplace and Address: Date of Birth PETITION FOR ORDER OF PROTECTION 5. _____ I am the Petitioner and am (a) _____ at least 18 years of age; (or)(b) _____ under 18, but emancipated. 6. _____ I am filing on behalf of myself. 7. _____ I am filing on behalf of a family or household member who is: _____ a minor: (full names) _____ an adjudicated incompetent person: (name) 8. _____ The Respondent is: (a) _____ at least 18 years of age; or (b) _____ under 18, but emancipated. 9. The Respondent and Petitioner (or Victim, if filing on behalf of a minor or incompetent person): (Check One) _____ are spouses/date of separation __________ _____ are blood relatives _____ are parent and child _____ currently reside together or cohabitate _____ are former spouses _____ child in common _____ are/were in a dating relationship _____ formerly resided together or cohabitated/date of separation __________ 10. If Order of Protection of children is requested: NAMES OF CHILDREN DATE OF BIRTH ADDRESS RELATIONSHIP TO PET/RES. American LegalNet, Inc. www.USCourtForms.com 11. The Respondent has committed domestic abuse to the Petitioner or Victim by the following acts(s): (briefly describe with date(s) of incident(s): _______________________________________________________________________________________________ _______________________________________________________________________________________________ ______________________________________________________________________________________________. 12. ___1. I am afraid of the Respondent and there is an immediate and present danger of domestic abuse to me because: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ ___2. The Respondent is scheduled to be released from incarceration within 30 days and upon the Respondent’s release, there will be an immediate and present danger of domestic abuse to me. The reason(s) are as follows: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 13. ___ Petitioner requests that the court issue an Ex Parte Order of Protection with the following provisions: (Check all that apply) (a) __ Excluding the Respondent from a shared residence or from the residence of the Petitioner or Victim. Address of Residence: _________________________________________________________________________ (b) __ Excluding the Respondent from the place of business, employment, school, or other locations of the Petitioner or Victim. Address of: Employment Address: _________________________________________________________________________ School Address: ______________________________________________________________________________ Other: ______________________________________________________________________________________ (c) __Awarding temporary custody of the minor children of the Petitioner and Respondent as follows: Child’s Name Person to receive custody (d) ___ Excluding the Petitioner’s address from Notice to the Respondent. (e) Civil Standby Requested? Yes___ No ___. For Petitioner or Respondent? _______________________ Address where Civil Standby is needed: ___________________________________________________________ 14. It is further requested that upon hearing, the court issue a full Order of Protection with the following provisions: (Check all that apply) (a) ____Excluding the Respondent from a shared residence or from the residence of the Petitioner or Victim. Address of residence: ____________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com (b) ___ Excluding the Respondent from the place of business, employment, school, or other location of the Petitioner or Victim. Addresses of: Employment address: ___________________________________________________________________ School address: ________________________________________________________________________ Other: ________________________________________________________________________________ (c) ___ Awarding custody of the minor children as follows: Person to receive custody Child’s Name (d) If visitation is allowed, name, address, and phone number of third party to provide transportation: Name: _________________________________________________________________________ Address: ________________________________________________________________________ Phone Number: (_______) __________________________________________________________ 15. Is there a pending divorce action between the parties _____________? If yes, give Case Number: ________________ Petitioner’s Attorney: ___________________________ Respondent’s Attorney: _____________________________ 16. The Petitioner, under oath, states that the facts stated in the above petition are true according to the Petitioner’s best knowledge and belief. __________________________________ _____________________________________________________ Date Petitioner’s Signature STATE OF ARKANSAS COUNTY OF BENTON Subscribed and sworn to me this ______________ day of _________________, 200___. Brenda DeShields ________________________ Circuit Clerk _____________________________ Deputy Clerk Petitioner hereby agrees and acknowledges that he/she will be present in Court at the time set for a hearing on this matter to give testimony. If you do not show up for your court date, you may be charged $190.00. ___________________________________ Petitioner’s Signature American LegalNet, Inc. www.USCourtForms.com AFFIDAVIT OF DOMESTIC ABUSE (To be used if Temporary Order is requested.) 1. PREVIOUS HISTORY: (INCLUDING DATES) of domestic abuse between Petitioner and Respondent which includes: Physical harm, bodily injury, assault, or the infliction of fear of imminent physical harm, bodily injury, or assault, or any sexual conduct which would constitute a crime in the state of Arkansas. 2. Existence of IMMEDIATE DANGER to your person or members of your household. State in detail date and time of most recent incidents or conduct by giving specific act(s) and circumstances of alleged abuse. American LegalNet, Inc. www.USCourtForms.com 3. If members of your household are also in danger, include names, ages, and any physical handicaps. 4. Have you reported the last occurrence of abuse to any law enforcement agency? (If so, state to what agency and date.) 5. Has the Respondent been arrested or convicted previously of any acts of violence? (If so, where and when?) The above statements are true and correct and I request a Temporary Order of Protection. _________________________________ Petitioner’s Signature Above statements given under oath this ________ day of _________________, 200 ___. _______________________________ Brenda DeShields, Circuit Clerk By: __________________________________, D.C. American LegalNet, Inc. www.USCourtForms.com BENTON COUNTY SHERIFF’S OFFICE Location/Direction Log Please answer the following to the best of your knowledge. Any information will help the deputy serve the Order. NOTE: INFORMATION ON THIS SHEET IS FOR LAW ENFORCEMENT USE ONLY. PETITIONER’S NAME: _____________________________________________________________________________ Petitioner’s Phone Number: _____________________________________________________________________________ RESPONDENT’S NAME AND DATE OF BIRTH: ____________________________________________/___________ Respondent’s Physical Description: (Ht.) __________ (Wt.) ___________ (Hair) ____________ (Eyes) _________________ Respondent’s Phone Numbers: (Home): __________________ (Cell): __________________ (Message): _________________ Respondent’s Address AND Directions: _____________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Respondent’s Employment & Work Number: _________________________________________________________________ Respondent’s Work Hours: _______________________________________________________________________________ Respondent’s nearest relative and phone number: ______________________________________________________________ Address and/or Directions: ________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Respondent’s Vehicle (Including: Make, model, color, & tag number): ____________________________________________ Other Information that may be helpful to locate Respondent: ____________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ PLEASE FILL OUT IN DETAIL-THIS HELPS US HELP YOU!! 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