AFFIDAVIT - RELIEF FROM ABUSE JD-FM-138 Rev. 10-14 C.G.S. �� 46b-15, 52-231a, P.B. � 25-57 STATE OF CONNECTICUT For Court Use Only SUPERIOR COURT www.jud.ct.gov AFFRFA *AFFRFA* Instructions to Person Applying for Relief from Abuse (Affiant) This affidavit must be filled out completely and given to the clerk along with your filled out Application for Relief From Abuse, form JD-FM-137. 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. Do not write on the back of this form. If you need additional room, use another Affidavit - Relief From Abuse form, JD-FM-138. You must sign and swear to all pages. If you are asking for temporary custody of your minor child or minor children, you must also fill out an Affidavit Concerning Children, form JD FM 164. Name of applicant (Your name) Name of respondent (Person you want a restraining order against) Docket number (For court use only) Statement Of Conditions From Which You Seek Relief I, the person signing below, duly depose and say that I am the Applicant in this matter and state 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.) Statement Concerning Temporary Custody Of Children "X" one of the following: I am not asking for temporary custody of any minor child or minor children in this matter. I am asking for temporary custody of my minor child or minor children in this matter. (Fill out an Affidavit Concerning Children, form JD-FM-164, and bring it to the clerk along with this form and your filled out Application For Relief From Abuse, form JD-FM-137.) I certify that the statements above are true to the best of my knowledge and belief. Signature Print name of person signing Subscribed and sworn to before me (Assistant Clerk, Commissioner of Superior Court, Notary Public) Date signed American LegalNet, Inc. www.FormsWorkFlow.com