You must provide a government-issued ID in order to have your signature notarized. Petitions will not be filed without a notarized signature. GENERAL INSTRUCTIONS FOR THOSE SEEKING A PROTECTION FROM ABUSE ORDER NOTICE The protection from abuse process is designed to provide quick and immediate protection. However, the process may require time, expertise, or more than one hearing. If you have questions, you should seek help from an attorney or victim services advocate. The Kansas Crisis Hotline (1-888-363-2287) or Kansas Legal Services (1-800-723-6953) may be able to help you find an attorney or advocate. These are basic forms and they do not cover every situation. The Clerk of the District Court cannot help you with these forms. The Clerk cannot give legal advice to you or tell you about your rights or responsibilities. The Clerk can only provide very limited information about the protection order process. You can find more information about protection from abuse at http://www.kcsdv.org/pfa.html. 1. You may seek a protection from abuse order: a. For yourself; or, b. For yourself and your minor child(ren); or, c. For only your child(ren) or other minor child(ren) who reside with you. 2. For each person for whom protection is sought, Kansas law requires a former or current “intimate partner or household member” relationship with the defendant. “Intimate partner or household member” relationship means: a. Persons who are in a dating relationship (a social relationship of a romantic nature); or, b. Persons who have been in a dating relationship; or, c. Persons who live together; or, d. Persons who have lived together; or, e. Persons who have had a child in common. 3. 05/27/09 Each person needing protection must have been abused. This means that one of the following must have occurred: a. The defendant physically hurt you or a minor child on purpose; or, b. The defendant tried to physically hurt you or a minor child; or, c. The defendant threatened to physically hurt you or a minor child; or, d. The defendant engaged in sexual conduct (touching or sexual intercourse) with a minor child under 16 years of age. 1 American LegalNet, Inc. www.FormsWorkFlow.com 4. You must notify the defendant by personal service that you have filed a Petition for a Protection from Abuse Order. To obtain personal service, you must fill out a Request for Service Form, requesting that the sheriff deliver the Petition for Protection from Abuse to the defendant. 5. If the defendant is a minor, you must complete the Minor Defendant Addendum. Petitions, Motions and Temporary Protection from Abuse Orders filed against a minor defendant must be served by serving the minor and: a. The minor’s guardian or conservator, if any; or, b. The minor's father or mother; or, c. A person having the minor's care or control; or, d. A person with whom the minor resides. If service cannot be made upon any of these people, then service may be obtained as provided by order of the judge. 6. You should be available to testify at future hearings as set by the judge. If you fail to appear, the case may be dismissed. 7. A Final Protection from Abuse Order will expire after one year or on the date stated in the order unless you request an extension or modification from the court before the order expires. 8. If you are the defendant and you want an order restraining the plaintiff from abuse, you must file a written counter petition. 9. If you decide to seek child support, it is highly recommended that you seek the advice of an attorney. In order to obtain child support, you must complete a Domestic Relations Affidavit and a Child Support Worksheet and attach them to the Petition for Protection from Abuse. If the court grants child support, the court will complete the Child Support Addendum and attach it to the Final Protection from Abuse Order. You will then need to complete a Kansas Payment Center Form, attach it to a copy of the Final Protection from Abuse Order including the Child Support Addendum and provide it to the Clerk of the District Court. 05/27/09 2 American LegalNet, Inc. www.FormsWorkFlow.com IN THE DISTRICT COURT OF DOUGLAS COUNTY, KANSAS ____________________, Plaintiff vs. Case No. _______________ ____________________, Defendant PROTECTION FROM ABUSE CONFIDENTIAL ADDRESS FORM (K.S.A. 60-3104(e)) NOTE: IF THE COURT FINDS THAT THE PLAINTIFF’S ADDRESS AND TELEPHONE NUMBER NEED TO REMAIN CONFIDENTIAL FOR THE PROTECTION OF THE PLAINTIFF OR THE MINOR CHILD(REN), THIS FORM WILL BE SHOWN ONLY TO AUTHORIZED COURT OR LAW ENFORCEMENT PERSONNEL AND WILL NOT BE DISCLOSED TO THE PUBLIC OR TO THE DEFENDANT. IT IS THE PLAINTIFF’S RESPONSIBILITY TO NOTIFY THE COURT OF ANY CHANGE IN ADDRESS OR TELEPHONE NUMBER. Name of Plaintiff: Confidential Address: Street Zip Code City ________________________ State Phone Number ________________________________ 05/27/09 3 American LegalNet, Inc. www.FormsWorkFlow.com ___________________________________ Plaintiff vs. Case No. _______________ Div. No. ________________ ___________________________________ Defendant PERSONAL AND SERVICE DATA SHEET The purpose of this sheet is to provide the Sheriff’s Department with the necessary information to effect service on Defendant and to provide essential information for the safety of the Sheriff’s Deputy. Information about Defendant is voluntary on the part of the Plaintiff, except physical description and information. In addition, this page establishes a contact number for returning keys to the residence, re-entering the house, or obtaining custody of any children involved. This page is for the Court and Sheriff’s use only and will not be part of the packet served to Defendant. PRINT CLEARLY. PLAINTIFF’S INFORMATION (YOU) Plaintiff’s Name: ________________________________________________________ Plaintiff’s Address: ______________________________________________________ _____________________________________________________________________ Phone Number where Plaintiff can be contacted: ______________________________ Does Defendant have keys to your current residence? ______________________ Do you want your address kept confidential so Defendant cannot obtain this information?_____________________________________________ Physical Description of PLAINTIFF (You): Race: _____________ Sex: _______ Age: ______ Date of Birth: ______________ Height: _________ Weight: ________ Hair: ________________ Eyes: __________ 05/27/09 4 American LegalNet, Inc. www.FormsWorkFlow.com DEFENDANT’S INFORMATION Defendant’s Name:______________________________________________________ Other name(s) Defendant may go by/be known as:______________________________ _____________________________________________________________________ Defendant’s Social Security Number (if known):________________________________ Name of Defendant’s Employer: ____________________________________________ Defendant’s Work Hours: _________________________________________________ Does Defendant Operate a Business from his/her Home? ______________ Does Defendant require a language interpreter? ___ Yes ___ No If so, what language? ____________________________________________________ Physical Description of Defendant: (Please attach current photo if available) Race: _____________ Sex: _______ Age: ______ Date of Birth: ______________ Height: _________ Weight: ________ Hair Color/Length: _____________________ Eye Color: __________ Glasses?_______ _ Other Identifying Characteristics (i.e. scars, tattoos, etc.) ____________________________________________________ Description of Defendant’s Vehicle: _________________________________________ Places Defendant is likely to be found:_______________________________________ Has Defendant been arrested? ____________ If so, why? ____________________________________________________________ _____________________________________________________________________ Does Defendant own any weapons? ____________ If so, what kinds? _______________________________________________________ ______________________________________________________________________ Does Defendant have a history of drug or alcohol abuse? _____________ If so, please explain: _____________________________________________________ ______________________________________________________________________ Does Defendant have a history of domestic violence? ____________ If so, please explain: _____________________________________________________ ______________________________________________________________________ Does Defendant have a history of mental illness? ___________ If so, please explain: _____________________________________________________ ______________________________________________________________________ 05/27/09 5 American LegalNet, Inc. www.FormsWorkFlow.com The defendant can be found at: (give all available addresses) HOME: Street __________________________________________________________ City ________________________ State ______________ Zip Code __________ Phone number ____________________________________________________ Times when defendant is usually there _________________________________ WORK: Street __________________________________________________________ City ________________________ State ______________ Zip Code __________ Phone number ____________________________________________________ Times when defendant is usually there _________________________________ OTHER: Please explain ____________________________________________________ Street ___________________________________________________________ City ________________________ State ______________ Zip Code _________ Phone number ____________________________________________________ Times when defendant is usually there _________________________________ 05/27/09 6 American LegalNet, Inc. www.FormsWorkFlow.com IN THE DISTRICT COURT OF DOUGLAS COUNTY, KANSAS ________________________________ Plaintiff Case No. ____________________ vs. ________________________________ Defendant PETITION FOR PROTECTION FROM ABUSE ORDER (K.S.A. 60-3101 et seq.) 1. Plaintiff seeks an order for protection from abuse: For Plaintiff Only, or a. (Kansas law requires a former or current relationship which may be established by any one of the following options.) i. Plaintiff and Defendant: are in a dating relationship were formerly in a dating relationship reside together in the same residence formerly resided together in the same residence have a child in common b. For Plaintiff and Plaintiff’s minor child(ren), or (Kansas law requires a former or current relationship which may be established by any one of the following options.) i. Plaintiff and Defendant: are in a dating relationship were formerly in a dating relationship reside together in the same residence formerly resided together in the same residence have a child in common ii. Plaintiff’s minor child(ren) and Defendant: reside together in the same residence formerly resided together in the same residence 05/27/09 7 American LegalNet, Inc. www.FormsWorkFlow.com c. Only on behalf of Plaintiff’s minor child(ren) or minor child(ren) residing with Plaintiff (Kansas law requires a former or current relationship which may be established by any one of the following options.) i. Minor child(ren) and Defendant: are in a dating relationship were formerly in a dating relationship reside together in the same residence formerly resided together in the same residence have a child in common The minor child(ren) for whom Plaintiff seeks protection are: (give full names and year of birth) NAME YOB MOTHER’S NAME FATHER’S NAME 2. Defendant can be served at: (please provide all available addresses) HOME: street city zip code phone number state times when defendant is usually there city WORK: street zip code phone number state times when defendant is usually there city OTHER: street zip code phone number state times when defendant is usually there 3. Plaintiff seeks protection from abuse because Defendant: (check all that apply) caused Plaintiff bodily injury or attempted to cause Plaintiff bodily injury placed Plaintiff in fear of imminent bodily injury by threatening Plaintiff caused the minor child(ren) bodily injury or attempted to cause the minor child(ren) bodily injury placed the minor child(ren) 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 Defendant: sexual intercourse or lewd fondling or touching on the person of either the minor or Defendant. 05/27/09 8 American LegalNet, Inc. www.FormsWorkFlow.com 4. 05/27/09 Describe why Plaintiff seeks a protection from abuse order and include specific facts: 9 American LegalNet, Inc. www.FormsWorkFlow.com (Attach additional pages as needed.) 5. address and/or telephone number remain Plaintiff requests that Plaintiff’s confidential for the following reason(s): (complete if appropriate) (If Plaintiff requests that Plaintiff’s address remain confidential, Plaintiff must complete the Protection from Abuse Confidential Address Form and include it with this petition.) 6. Plaintiff requests that the Court issue an Ex Parte Temporary Order of Protection and Final Order of Protection restraining defendant from: abusing, molesting or interfering with the privacy or rights of the protected person(s) entering or coming on or around the premises or the residence of the protected person(s) located at: , . and the workplace located at: 05/27/09 10 American LegalNet, Inc. www.FormsWorkFlow.com (Give address or other description of residence and workplace from which Defendant is to be excluded. DO NOT include the residential address if Plaintiff is requesting that Plaintiff’s residential address is to remain confidential.) 7. Plaintiff states the residence is: jointly owned, or rented and jointly occupied by Plaintiff and Defendant owned, or rented by Plaintiff owned, or rented by Defendant only owned, or rented by someone else (explain) not applicable because the Plaintiff and Defendant do not live together. 8. Plaintiff requests the Court order that the Defendant immediately move from and not return to the residence, and that Law Enforcement officers be directed to remove Defendant from the residence, located at: . Plaintiff requests that the Court issue an Ex Parte order of temporary custody of the minor children and has attached a completed form concerning jurisdiction (UCCJEA form). (Complete either option (a.) OR option (b.)) Defendant’s parentage of the child(ren) has not been established and Defendant has no right a. to custody or parenting time with the child(ren). Defendant’s parentage of the child(ren) has been established and the Plaintiff requests the b. following custody and parenting time orders: i. Temporary legal custody and residency of the minor child(ren) be: Joint legal custody between Plaintiff and Defendant until this order expires; or, Sole legal custody granted to Plaintiff, Defendant until this order expires. ii. Rights of temporary parenting time as follows: Plaintiff and Defendant shall have parenting time as described in the attached parenting plan; or Defendant shall have no parenting time; or Defendant shall have supervised parenting time as follows: . Plaintiff and Defendant shall exchange the minor child(ren) for parenting time at: . 9. The court should give copies of orders to the appropriate law enforcement agencies; set a date, time and hearing on this matter; and issue summons to Defendant, notifying Defendant of this action and the relief requested. 10. After a hearing, the court should issue a final order of protection prohibiting Defendant from committing any acts of abuse against the protected person(s), and order the following additional relief: suitable alternate housing for Plaintiff and minor child(ren) 05/27/09 11 American LegalNet, Inc. www.FormsWorkFlow.com custody of the minor child(ren) (UCCJEA form completed) child support support of spouse possession of personal property, and the assistance of law enforcement officers in securing that property, if necessary attorney’s fees, if represented by counsel, and costs counseling for Defendant other, please specify: 11. The following legal actions have been filed between Plaintiff and Defendant or involving the minor child(ren): (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 __________________________________________ Plaintiff’s signature Plaintiff’s Name: Address 1: Address 2: City, State, Zip: Telephone Number: (DO NOT include the residential address if Plaintiff is requesting that Plaintiff’s residential address is to remain confidential. If Plaintiff requests that Plaintiff’s address remain confidential, Plaintiff must complete the Protection from Abuse Confidential Address Form and include it with this petition.) Attorney representing Plaintiff (if any) Attorney’s Name: Address 1: Address 2: City, State, Zip: Telephone: VERIFICATION STATE OF ____________________ ) ) ss: COUNTY OF __________________ ) 05/27/09 12 American LegalNet, Inc. www.FormsWorkFlow.com I swear or affirm that the statements made in this Petition are true and correct to the best of my knowledge and belief and that I am the person filing this petition. __________________________________________ Plaintiff’s signature SUBSCRIBED AND SWORN to before me, a Notary Public, this ______ day of _______________________________ 20 . __________________________________________ Notary Public My Appointment Expires: ___________________ 05/27/09 13 American LegalNet, Inc. www.FormsWorkFlow.com IN THE DISTRICT COURT OF DOUGLAS COUNTY, KANSAS ____________________, Plaintiff vs. Case No. _______________ ____________________, Defendant UNIFORM CHILD CUSTODY JURISDICTION AND ENFORCEMENT ACT (UCCJEA) AFFIDAVIT (K.S.A. 60-3101 et seq.) I, (full legal name) sworn, certify that the following statements are true: , of lawful age, being first duly 1. The names and dates of birth of the children now under eighteen years of age and subject to this proceeding are: a.__________________________ (child’s name), was born in _______ (month) _______ (year). b.__________________________ (child’s name), was born in _______ (month) _______ (year). c.__________________________ (child’s name), was born in _______ (month) _______ (year). d.__________________________ (child’s name), was born in _______ (month) _______ (year). 2. The child(ren) now live with:________________________________ (name of adult) at ______________________________________________________________ (Street address), ________________________________________ (city), ______________ (state) and have lived at this place since ___________________________ (date). *If you are the petitioner and have requested that the court keep your address confidential pursuant to K.S.A. 60-3104(e), you should write “confidential” in any space that would require you to enter the address where you are currently living. 3. All the children lived together at the following addresses with the adults listed during the past five years. If the children lived at different addresses from each other, complete this information for each child separately using the spaces provided on page four. Make additional copies of page four as needed. Name and Relationship of From Date Until Date City, State Adult(s) Living with Child, and Adult(s) Present Address 14 American LegalNet, Inc. www.FormsWorkFlow.com *If you are the petitioner and have requested that the court keep your address confidential pursuant to K.S.A. 60-3104(e), you should write “confidential” in any space that would require you to enter the address where you are currently living. 4. I have have not been involved in a court case involving the custody or visitation of the child(ren). The following court cases are on file about the child(ren): Type of Case Court, City and State Case Number Last Order Date have do not have information concerning ANY OTHER proceeding that 5. I could affect the current proceeding, including but not limited to proceedings for enforcement and proceedings relating to domestic violence, protective orders, termination of parental rights and adoption. The following court cases are on file and could affect the current proceedings: Type of Case Court, City and State Case Number Last Order Date 6. The following named persons not a party to this proceeding have physical custody or 15 American LegalNet, Inc. www.FormsWorkFlow.com claim to have custody or visitation rights with respect to any child subject to this proceeding: None Name Address, City and State Check the box that applies Has Physical Custody Claims Custody Rights Claims Visitation Rights Has Physical Custody Claims Custody Rights Claims Visitation Rights Has Physical Custody Claims Custody Rights Claims Visitation Rights Has Physical Custody Claims Custody Rights Claims Visitation Rights Has Physical Custody Claims Custody Rights Claims Visitation Rights 7. I acknowledge that I have a continuing duty to inform the court of proceeding(s) in this or any other state that could affect the current proceeding. VERIFICATION STATE OF ____________________ ) ) ss: COUNTY OF __________________ ) I swear or affirm that the statements made in this Affidavit are true and correct to the best of my knowledge and belief and that I am the person filing this affidavit. __________________________________________ Plaintiff’s signature SUBSCRIBED AND SWORN to before me, a Notary Public, this ______ day of _______________________________ 20 . __________________________________________ Notary Public My Appointment Expires: ___________________ (Make as many copies of this page as necessary.) 16 American LegalNet, Inc. www.FormsWorkFlow.com THE FOLLOWING INFORMATION IS TRUE: (Child’s Full Legal Name) , lived at the following address(es) with the adult(s) listed during the past five years: Name and Relationship of From Date Until Date City, State Adult(s) Living with Child, and Adult(s) Present Address *If you are the petitioner and have requested that the court keep your address confidential pursuant to K.S.A. 60-3104(e), you should write “confidential” in any space that would require you to enter the address where you are currently living. THE FOLLOWING INFORMATION IS TRUE: (Child’s Full Legal Name) , lived at the following address(es) with the adult(s) listed during the past five years: Name and Relationship of From Date Until Date City, State Adult(s) Living with Child, and Adult(s) Present Address *If you are the petitioner and have requested that the court keep your address confidential pursuant to K.S.A. 60-3104(e), you should write “confidential” in any space that would require you to enter the address where you are currently living. 17 American LegalNet, Inc. www.FormsWorkFlow.com COMPLETE IF SERVING DEFENDANT AT PLACE OF EMPLOYMENT IN THE DISTRICT COURT OF DOUGLAS COUNTY, KANSAS ______________________________ Plaintiff Vs. Case No. _________ Div. No. ___________ ______________________________ Defendant AFFIDAVIT AND REQUEST FOR SERVICE AT PLACE OF EMPLOYMENT STATE OF KANSAS ) ) ss: COUNTY OF DOUGLAS ) I, ____________________________________________, Plaintiff, having been duly sworn on oath, state as follows: I request that the defendant be served at his place of employment because: [Please check one] _____ the defendant is a non-resident who is employed in the State. _____ the defendant’s place of residence is unknown. Please serve the defendant by personal service only at: Name of employer:________________________________________________ Address of employer:_______________________________________________ ________________________________________________________________ _____________________________ Plaintiff’s signature Subscribed and sworn to before me this _______ day of ___________________,20____ __________________________________ Deputy Clerk of District Court/Notary Public My Appointment Expires: _____________ 18 American LegalNet, Inc. www.FormsWorkFlow.com