AFFIDAVIT - CIVIL PROTECTION ORDER JD-CV-144 Rev. 10-16 C.G.S. § 46b-16a STATE OF CONNECTICUT 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 This affidavit must be filled out completely and given to the clerk along with your filled out Application for Civil Protection Order (form JD-CV-143). 1. Your affidavit must include a statement of the conditions you seek relief from and must be made under oath (you must swear that your statement is true and sign it in front of a court clerk, a notary public, or an attorney who will also sign and date the affidavit). The statement must be true to the best of your knowledge. State if any arrest was made related to the incidents outlined in this statement. 2. Even if the applicant is under 18 years of age and represented by a next friend, this Affidavit must be completed by the applicant, not the next friend. 3. You must sign and swear to all pages. Do not write on the back of this form. If you need additional room, use another Affidavit - Civil Protection Order (form JD-CV-144). Name of applicant (Your name) Name of next friend (If applicant is a minor) Name of respondent (Person you want a restraining order against) Docket number (For court use only) Instructions to Person Applying for a Civil Protection Order (Affiant) Statement Of Conditions From Which You Seek Relief I, the person signing below, say under oath that I am the applicant for this Civil Protection Order and state I have been the victim of sexual abuse, sexual assault or stalking (as described in sections 53a-181c, 53a-181d and 53a-181e of the Connecticut General Statutes) by the respondent as follows: (Explain for each incident: (1) what happened, (2) when it happened, (3) where it happened, and (4) who was there when it happened.) Notice u Any false statement made by you under oath which you do not believe to be true and which is intended to mislead a public servant in the performance of his or her official function may be punishable by a fine and/or imprisonment. Signature of applicant Print name of person signing Date signed I certify that the statements above are true to the best of my knowledge and belief. Subscribed and sworn to before me (Assistant Clerk, Commissioner of Superior Court, Notary Public) American LegalNet, Inc. www.FormsWorkFlow.com