IN THE ______ JUDICIAL CIRCUIT COURT, ___________________________, MISSOURI Judge or Division: Petitioner: vs. Respondent: Alias/Nicknames: Respondent's DOB: Age: SSN (if known, last four digits): Race: Case Number: Court ORI Number: MSHP Number: Responsible Law Enforcement ORI: Related Cases: Respondent's Home Address: Home Phone Number: Respondent's Work Address: Work Phone Number: Work Hours: Other Locations Where Respondent May Be Served: Petitioner's Relationship to Respondent pursuant to 18 U.S.C. §§ 921(a)(32) and 922(g)(8) determination: Spouse Child(ren) in common Former spouse Intimate residing/resided together Are/were in a continuing social relationship of a romantic/intimate nature Related by blood. Define relationship: Related by marriage. Define relationship: Residing/resided together; no intimacy Stalking. Define relationship: (Date File Stamp) Sex: F M Affidavit of Changes in Circumstance and Motion to Modify Adult Abuse/Stalking Judgment Entry Full Order of Protection An Adult Abuse/Stalking Judgment of the Full Order of Protection was entered in ____________________________ County, Missouri, on ____________________________ (date). A change has occurred in the circumstances of the petitioner, respondent or child(ren) and the modification is necessary to serve the best interests of the parties. Below are the specific facts, including dates and times, which petitioner respondent believes forms grounds for modification of the court's judgment: I request that the court find grounds for modification of: (check the box that applies) Installments of maintenance or support. Conditions regarding communication. Custody. Conditions regarding contact. Visitation. Other (specify): __________________________________________________________________________________________ The specific modification that I am requesting is: I swear /affirm under penalty of perjury that these facts are true according to my best knowledge and belief. _________________________________________ Date _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Your Telephone Number City State Zip Your Street Address Your Signature NOTICE: Section 455.030.3, RSMo provides that a Petitioner seeking protection under the Domestic Violence Act is not required to reveal any current address or place of residence on this motion. Do not provide this information if doing so will endanger you. In witness thereof: _______________________________ Date _______________________________________________ Clerk Witnessing Signature Subscribed and sworn to before me on ___________________________________ (date). (Seal) Date Notary Public Directions for Completing This affidavit must be completed and signature witnessed by a court clerk or notary before filing it with the court. OSCA (07-13) AA52 1 of 1 My commission expires: __________________ ___________________________________ 455.060, 455.065 RSMo American LegalNet, Inc. www.FormsWorkFlow.com