Case Type: DVI IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA AT Petitioner ) ) ) ) ) ) ) ) ) ) Date of Birth v. Respondent Date of Birth CASE NO. PETITION FOR PROTECTIVE ORDER (DOMESTIC VIOLENCE) I, petitioner, swear or affirm under penalty of perjury that all the information I provide in this petition is true to the best of my knowledge and belief. 1. I am requesting (check all that apply) a 20-day protective order. (This order, called an "ex parte" order, can take effect immediately without prior notice to the respondent.) I understand that I can get a 20-day order without prior notice to the respondent. However, the law requires that I tell the court about any efforts I have made to notify the respondent. I certify that I have not tried to notify the respondent that I am filing this petition. notified or tried to notify the respondent as follows: a long-term protective order. (This order can only be issued after notice to the respondent and a court hearing. Most provisions of this order will last for one year. However, the provision that prohibits the respondent from committing domestic violence will last indefinitely (until the court terminates it).) NOTE: If there is any chance you might need protection for more than 20 days, you should request both a long-term order and a 20-day order. To do this, check both boxes. 2. The respondent is (check all that apply) my spouse my child my first cousin my former spouse my grandchild my aunt my parent my brother my uncle my grandparent my sister my nephew my niece a person with whom I presently have or previously had a dating or sexual relationship. someone who lives or has lived with me. a person related or formerly related to me by marriage (for example, stepparent, stepchild) other (specify relationship) Page 1 of 6 DV-100 (1/07)(st. 4) PETITION FOR PROTECTIVE ORDER (DOMESTIC VIOLENCE) AS 18.66.100-.990/ Civil Rule 65.1 American LegalNet, Inc. www.FormsWorkflow.com 3. There are children in my household. yes no 4. I have been the victim of domestic violence by respondent as described below. (Include date of incident, place where incident occurred and injuries suffered, if any. List the most recent incident first and specify whether weapons or children were involved. Attach additional sheets if necessary.) 5. Has the respondent been involved in other instances of domestic violence? 6. I request an order from the court directing (check all that apply) a. respondent not to threaten or commit acts of domestic violence, stalking, or harassment. b. respondent not to telephone, contact, or otherwise communicate directly or indirectly with me. Exceptions (if any): c. respondent to leave and stay away from my residence. Exception: I request an order directing a peace officer to accompany the respondent to my residence to remove respondent's essential personal belongings including This is also respondent's current residence. (If yes, answer the following.) yes no (1) The address is: (2) The residence is also used for business purposes. If yes, describe: yes no (3) The title or lease for the residence is in the name of: (Note: Temporary possession of the residence may be given to the petitioner regardless of ownership of the residence. AS 18.66.100(c)(3)) Page 2 of 6 DV-100 (1/07)(st. 4) PETITION FOR PROTECTIVE ORDER (DOMESTIC VIOLENCE) AS 18.66.100-.990// Civil Rule 65.1 American LegalNet, Inc. www.FormsWorkflow.com d. respondent to stay away from and not telephone or contact the following additional locations: my school my place of employment the following places frequented by me or by the member of my household listed below: Place Name of Household Member Exceptions e. respondent not enter or follow a vehicle in my possession or occupied by me. f. I be given temporary possession and use of the following, regardless of ownership: a vehicle and all keys to it. Vehicle license number: Vehicle Description: essential personal items, including: g. a peace officer to accompany me to my residence to ensure that I: safely obtain possession of the residence and any vehicle or personal items which the court gives temporary possession of to me. am able to safely remove a vehicle and personal items from my residence. h. respondent not to possess or use controlled substances. i. respondent to pay support to me. I understand that support cannot be awarded unless the respondent has an independent legal obligation to support me. (1) $ $ (2) Respondent's monthly income from all sources Respondent's monthly expenses $ $ (3) j. My estimated monthly income from all sources My estimated monthly expenses I have been since completely partly supported by the respondent . other: Page 3 of 6 DV-100 (1/07)(st. 4) PETITION FOR PROTECTIVE ORDER (DOMESTIC VIOLENCE) AS 18.66.100-.990// Civil Rule 65.1 American LegalNet, Inc. www.FormsWorkflow.com 7. I also request that the following be included in the long-term protective order. I understand that these requirements cannot be included in the 20-day order. I request that the court direct: a. respondent not to use or possess a deadly weapon (including a firearm). b. respondent to surrender any firearm owned or possessed by respondent. c. respondent to reimburse me or the person named below for expenses associated with the domestic violence (such as medical expenses, counseling, shelter, and repair or replacement of damaged property) as described below: Pay to Type of Expense Amount $ $ $ d. respondent to pay to incurred in bringing this action, in the amount of $ the costs and fees I have . e. respondent to enroll in and complete, at respondent's expense: a program for the rehabilitation of perpetrators of domestic violence that meets the standards set by the Department of Corrections under AS 44.28.020(b). treatment for the abuse of alcohol. treatment for the abuse of controlled substances. 8. Children. I request that the court enter the following orders concerning the child(ren). a. I request the court to award me temporary physical custody of the minor child(ren) named below: (1) Child's Name (2) Date of Birth How Long in Alaska My relationship to child is: Respondent's relationship to child is: The child(ren) and I have lived in Alaska for the past six months. yes no Page 4 of 6 DV-100 (1/07)(st. 4) PETITION FOR PROTECTIVE ORDER (DOMESTIC VIOLENCE) AS 18.66.100-.990// Civil Rule 65.1 American LegalNet, Inc. www.FormsWorkflow.com (3) There is a custody order over one or more of the children. yes no do not know If yes, describe each order below: Child's Name (4) I State that issued order Case No. (if known) The order grants custody to: currently have the child(ren) request an order directing a peace officer to assist me to obtain the child(ren) from who now has them. b. Visitation. I understand the court may only grant visitation to the respondent if my safety and the safety of the children can be protected. If the court considers visitation, these are my safety concerns: c. Child Support. I request that the court order the respondent to pay child support to me for the child(ren) named in section (a)(1) during the period I have temporary physical custody of them. yes no (1) Financial Information About Respondent. Respondent's Occupation: Name of Employer: Respondent's take-home pay: $ each week monthly every 2 weeks (2) Child support checks should be sent to: (mailing address safe to reveal to respondent) I understand that the above information is sufficient for the 20-day order. However, to get a long-term (one-year) child support order, I understand that I must complete form DV-101, Child Support Information, and bring it with me when I come back to court for the hearing on whether the long-term protective order will be granted. 9. Other Cases. a. The following are all the pending civil (for example, divorce or child custody) cases or domestic violence criminal cases, in this or another state, involving either me or respondent (that I know of): Type of Case Court Location Page 5 of 6 DV-100 (1/07)(st. 4) PETITION FOR PROTECTIVE ORDER (DOMESTIC VIOLENCE) Petitioner or Respondent AS 18.66.100-.990// Civil Rule 65.1 American LegalNet, Inc. www.FormsWorkflow.com b. The following are other court cases (civil or criminal) involving the respondent that I want the court to know about: Type of Case Court Location 10. Information About Respondent. Respondent’s full legal name and any nicknames or other names used: Respondent's Mailing Address: Respondent's Home Phone: Work Phone: 11. Petitioner Information. [The court needs your mailing address in order to send court papers, including notices of hearing, to you. If you believe you may endanger yourself by giving your mailing address, write a "message" address where you can be sure you will receive court papers. If you do not have an address and telephone number that can safely be revealed to the respondent, ask the court clerk how you can provide this information so that it will be kept confidential and not revealed to the respondent. Civil Rule 65.1] My mailing/message address is: Street or Box No. City State Zip My message phone: My full legal name: Any nicknames or other names: Date Petitioner's Signature Print Name Subscribed and sworn to or affirmed before me at on . (date) (SEAL) , Alaska Clerk of Court, Notary Public or other person authorized to administer oaths My commission expires: Page 6 of 6 DV-100 (1/07)(st. 4) PETITION FOR PROTECTIVE ORDER (DOMESTIC VIOLENCE) AS 18.66.100-.990// Civil Rule 65.1 American LegalNet, Inc. www.FormsWorkflow.com