APPLICATION FOR CIVIL PROTECTION ORDER STATE OF CONNECTICUT JD-CV-143 Rev. 10-16 C.G.S. �� 6-32, 46b-15, 46b-16a, 46b-38a, 51-5c, 53a-107, 53a-223 SUPERIOR COURT www.jud.ct.gov The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. ADA NOTICE Instructions To Person Filing Application (Applicant): 1. Fill out on-line, or print clearly in ink, or use a typewriter. You must also fill out an Affidavit - Civil Protection Order (form JD-CV-144). Give both forms to the Clerk of Court. 2. If the applicant is under 18 years of age, the Application must be signed and filed by an adult representative, also known as a "next friend". The next friend may be a parent, guardian or other responsible adult. The attached Affidavit (form JD-CV-144) must be completed by the applicant even if they are under 18 years of age and represented by a next friend. 3. After your Application and Affidavit are processed, the clerk will give you the proper papers to have served on (delivered to) the respondent (person the application is filed against). 4. Make sure the originals are returned to court after they are served on the respondent. Instructions To Clerk: 1. If Ex Parte relief is ordered, prepare the following forms: Order of Protection (form JD-CL-99); Additional Civil Protection Orders (form JD-CL-131) (If applicable); Order for and Notice of Court Hearing, Return of Service - Civil Protection Order (form JD-CV-145); General Notifications - Civil Protection Order (form JD-CL-129). 2. If the Court orders a hearing, prepare an Order for Notice of Court Hearing, Return of Service - Civil Protection Order (form JD-CV-145). 3. Provide the applicant with the original and three copies of the Application and Affidavit and three copies of any completed order form identified in instruction 1. 4. Retain copies of each for the court file. Judicial District of Name of applicant (Last, first, middle initial) Address to which mail is to be sent (Number, street)* (See NOTE below) Home/residence address* (See NOTE below) Work address* (See NOTE below) Same as mailing address Court location (number, street, town, zip code) Date of birth (mm/dd/yyyy) (Town) (Town) (Town) Sex (M/F) Docket number Race (State) (State) (State) (Zip Code) (Zip Code) (Zip Code) Name of next friend (Last, first, middle initial) (if applicant is a minor) Next friend address (town, state, Zip)* (See NOTE below) *NOTE: All addresses provided in this application will be included on papers that are in the court file and will be provided to the respondent. The applicant's address or addresses will determine which law enforcement agencies are notified if a Civil Protection Order is granted. Information About The Respondent (Person the application is filed against) Name of respondent (Last, first, middle initial) Address of respondent (Number, street) Respondent's telephone number Do you know the respondent? (Town) Other identifiers (Examples include height, weight and approximate age) Date of birth (mm/dd/yyyy) Sex (M/F) (State) Race (Zip Code) If yes, how do you know the Respondent: Yes No Yes No Is the respondent a member of your family or household? A member of � Your spouse or a person you have a civil union with your family or � Your former spouse or a person you had a civil union with household is � The parent of your child defined as: � Your parent � Your child � Someone you have cohabited with as an intimate partner (romantic, spousal, or sexual relationship while living together) � A person related to you by blood or marriage � A person you reside or resided with � A person you have (or recently had) a dating relationship with NOTE: If the respondent in your case is a family or household member, you DO NOT qualify for a Civil Protection Order and you should NOT continue to fill out this form. However, if the respondent is a family or household member you may qualify for an Order of Relief from Abuse under section 46b-15 of the Connecticut General Statutes. For more information, see Civil Protection Order Information Form (form JD-CV-148), and Restraining Orders: How to Apply for Relief from Abuse (form JDP-FM-142). "X" here if a Criminal Protective Order or Family Restraining Order exists affecting any party to this Application. (Enter docket number and court location) Docket number Court location Page 1 of 2 (continued on page 2) American LegalNet, Inc. www.FormsWorkFlow.com Name of applicant Name of respondent Docket number Application For Civil Protection Order 1. I have been the victim of one or more of the following by the respondent named above as explained more fully in my attached Affidavit: ("X" all that apply) Sexual Abuse Sexual Assault Stalking (as defined in sections 53a-181c, 53a181d, 53a-181e of the Connecticut General Statutes) 2. I have not obtained any other court order because of such sexual abuse, sexual assault or stalking. 3. The respondent is not a member of my family or household as defined in the Instructions and Information About the Respondent sections of this form. See sections 46b-15 and 46b-38 of the Connecticut General Statutes or the Civil Protection Order Information Form (form JD-CV-148) for more information. 4. I request that the court order the following conditions: ("X" all that apply) The respondent not assault, threaten, abuse, harass, follow, interfere with, or stalk me. (CT01) CT03 The respondent stay away from my home or wherever I shall reside. (CT03) CT05 The respondent not contact me in any manner, including by written, electronic or telephone contact, and not contact my home, workplace or others with whom the contact would be likely to cause annoyance or alarm to me. (CT05) CT16 The respondent stay 100 yards away from me. (CT16) CT01 5. I request that the court order the following other conditions: 6. I am in school and I request that a copy of the Civil Protection Order, if it is granted, be sent to my school Name of school Fax number of school (State) (Zip code) Address of school (Number, street) (Town) Request For Ex Parte (Immediate) Relief ("X" if this applies) 7. I request that the court order Ex Parte (immediate) relief because I believe I am in imminent danger. Signed (Applicant or next friend, if applicant is a minor) u Subscribed and sworn to before me: Signed (Clerk, Notary, Commissioner of Sup