Page 1 of 2 (continued on page 2) Your home/residence address* (See Note below) APPLICATION FOR RELIEF FROM ABUSE JD-FM-137 Rev. 1-18 C.G.S. 247247 29-28, 29-32, 29-33, 46b-15, 52-231a; P.A. 17-163STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.govRespondent is ("X" all that apply)A caretaker who is providing shelter in his or her residence to a(Give the docket number and court location, if known)*Note: Any addresses you provide will be included in the court file and will be provided to the Respondent. These addresses will also tell the court which law enforcement agencies must be notified if the court issues a restraining order. If you believe that giving out your home, work, or school address would put you and/or your children's health, safety or liberty in danger, you may use a mailing address that is different from your home or work address, including the address for the Safe at Home address confidentiality program, if applicable, but it is important to note that doing so may limit which law enforcement agencies receive notice of the order. You may also file a Request for Nondisclosure of Location Information form JD-FM-188 (which requires a mailing address) with the Clerk's Office.Information About the Respondent (Person the application is filed against) Judicial District of Court location (number, street, town, zip code) Docket number Your name (Applicant) (Last, first, middle initial) Date of birth (mm/dd/yyyy) Sex (M/F) Race Your mailing address (Number, street)* (See Note below) Town State Zip Code Same as mailing address Town State Zip Code Your work address* (See Note below) Town State Zip Code Respondent's name (Last, first, middle initial) Date of birth (mm/dd/yyyy) Sex (M/F) Race Respondent's address (Number, street) (Town) (State) (Zip Code) Respondent's telephone number Other identifiers (Examples include height, weight and approximate age) My spouse or a person I have a civil union with A person who is also the parent of my dependent child or Parent of my child My parent My child A person related to me by blood or marriage A person I reside or resided with A person I have (or recently had) a dating relationship with "X" here if you know about any other Protective Order or Restraining Order that exists involving you or the Respondent. Docket number Court location "X" here if a dissolution of marriage (divorce), dissolution of civil union, custody or visitation action exists involving you and the Respondent. Docket number Court location Someone I have cohabited with as an intimate partner (romantic, spousal, or sexual relationship while living240together) ADA NOTICE The Judicial Branch of the State of240Connecticut 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. If you are seeking additional orders of maintenance, check here(If you check this box, you must complete JD-FM-233, Request for Orders of Maintenance and submit it as part of your application)(If you check this box, you must complete JD-FM-233, Request for Orders of Maintenance and submit it as part of your application) If you are seeking additional orders of maintenance, check here(Give the docket number and court location, if known) Optional to Applicant (If you choose to answer, "X" the appropriate boxes below) 1. Does the Respondent hold a permit to carry a pistol or revolver? 2052052052052052052052053. Does the Respondent possess one or more firearms? 205205205205205205205205205205205205205 Unknown No Yes4. Does the Respondent possess ammunition? 205205205205205205205205205205205205205205205205205If you think you need more security when you are in court for your relief from abuse hearing, contact the Clerk's Office or the Court Service Center in the court where your hearing is scheduled. Yes No Unknown Yes No Unknown Unknown No Yes2. Does the Respondent hold an eligibility certificate for a pistol or revolver, a long gun eligibility certificate, or an ammunition certificate? 205205205205205205205205205205205205205205205children in common and we all live together.person 60 years of age or older *APPRFA* APPRFA COURT USE ONLY American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2JD-FM-137 Rev. 1-18 Subscribed and sworn to before me (Assistant Clerk, Commissioner of Superior Court, Notary Public)Request For Ex Parte (Immediate) Relief ("X" if this applies)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)I have been subjected to a continuous threat of present physical pain or physical injury, stalking or a pattern of threatening, by the Respondent named above as explained more fully in my attached Affidavit.danger to me and/or my minor children and/or animals owned or kept by me.Application For Relief From Abuse Name (Last, first, middle initial) Date of birth (mm/dd/yyyy) Date of birth (mm/dd/yyyy) Sex (M/F) Sex (M/F) Name (Last, first, middle initial)CT01CT03CT05CT14CT16CT19CT31CT20CT21CT22 Applicant's name Respondent's name Docket number 1. I ask 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) The Respondent stay away from my home or wherever I shall reside. (CT03) The Respondent may return to the home one time with police to retrieve belongings. (CT14) The Respondent stay 100 yards away from me. (CT16) That the order protect my minor children. (CT19) That the order protect animals owned or kept by me. (CT31) 2. I ask that the court make the following temporary child custody and visitation orders: Award me temporary custody of the following minor child(ren) who is (are) also the child(ren) of the Respondent. 1 2 3 4 5 6 With visitation as follows: Without visitation rights to the Respondent. 3. I ask that the court order the following: (further order) 4. I am in school and I ask that a copy of the restraining order, if it is granted, be sent to my school 6. I ask that the court order Ex Parte (immediate) relief because I believe there is an immediate and present physical Name (Last, first, middle initial) Date of birth (mm/dd/yyyy) Date of birth (mm/dd/yyyy) Sex (M/F) Sex (M/F) Name (Last, first, middle initial) 1 2 3 4 5 6 Name of school Fax number of school Address of school (Number, street) Town State Zip CodeIf I have moved out of the home of the Respondent, the Respondent shall permit me to return to the Respondent's home on one occasion, with police, to retrieve my belongings. (CT15) CT15 Date signed Print name of person signing Signature I certify that the statements above are true to the best of my knowledge and belief. 5. My minor child or children for whom I am also asking for protection is/are in school and I ask that a copy of the restraining Name of school Fax number of school Address of school (Number, street) Town State Zip Codeorder, if it is granted, be sent to my child's or children's school (attach additional sheets if necessary). American LegalNet, Inc. www.FormsWorkFlow.com