SUPERIOR COURT OF THE DISTRICT OF COLUMBIA DOMESTIC VIOLENCE UNIT (202) 879-0157 1 PETITION AND AFFIDAVIT FOR CIVIL PROTECTION ORDER Pursuant to D.C. Code Section 16-1001 et seq .; Petitioner respectfully requests that the court issue a 12-month Civil Protection Order against Respondent. In support of this request, Petitioner states: 1. Respondent is related to Petitioner By Blood; Legal Custody; Marriage; Having a Child in Common; Now or Previously Shared the Same Residence; Romantic /Dating Relationship; Stalking; 24716-1001(6)(B) Sexual Assault 2. Do you reside, live, work or attend school in the District of Columbia? Yes No 3. Did any incident described below occur in the District of Columbia? Yes No 4. Respondent committed or threatened to commit an act punishable as a criminal offense against Petitioner within the meaning of D.C. Code Section 16-1001 et seq ., by: (Please describe any such acts, including physical assaults like hitting, punching, shoving or kicking; threats to do harm, or destruction of property). A. On or about 20 at approximately a.m./p.m ., At (loc ation): Respondent B. On or about 20 at approximately a.m./p.m ., At (location): Respondent C . On or about 20 at approximately a.m./p.m ., At (location): Respondent D . On or about 20 at approximately a.m./p.m ., At (location): Respondent Your Name , Petitioner Your Address (If confidential, request a Confidential Address Form) Substitute Address CPO No: vs. Name of Individual Against Whom You Are Filing , Respondent American LegalNet, Inc. www.FormsWorkFlow.com ON THE BASIS OF THESE ALLEGATIONS, PETITIONER REQUESTS AN ORDER INCLUDING THE FOLLOWING RELIEF: (Check each form of relief you wish to be awarded by the court) 2 1. Ordering Respondent not to abuse, threaten, stalk or harass me, my children and 2 . Ordering Respondent to stay away from: my person; my work; my home; my vehicle other places I frequent ( describe ); other persons (names) 3 . Ordering Respondent not to contact me: by telephone; in writing; electronic or social media; in any other manner directly or indirectly through a third party. 4 . Awarding me temporary custody of the minor child, named below. ( state name and date of birth of each child AND bring birth certificates to court hearing ) IF YOU ARE SEEKING CUSTODY, PLEASE COMPLETE QUESTIONS 4a 4 e: 4 a. You do not have to reveal this information if doing so will put you in danger): 4 b. Over the past five years the children have lived at the following other addresses (if any): 4 c. Names and addresses of the people the children have lived with during the past five years: 4 d. Have you participated in or do you know of any other court cases concerning custody of these children? yes no 4 e. Do you know of any other person other than yourself and Respondent who claims to have custody of the children? yes 5 . Awarding Respondent visitation with the child(ren) if Respondent shows that the child(ren) and I can be adequately protected from harm by the Respondent. 6 . Ordering Respondent to pay child support for the above minor children, in an amount in accordance with the D.C. Child Support Guideline, through the Court Registry. To the best of my knowled . ( the court hearing, including 2 recent pay stubs, tax returns for the past two years or a completed financial statement. Also , bri ng proof of any other child support orders that affect you or the Respondent). IF YOU ARE SEEKING CHILD SUPP ORT, PLEASE COMPLETE QUESTIONS 6a 6 d: 6 a. Has a paternity and /or child support case already been filed regarding any of the above - listed children? yes , please indicate where the case was filed, the case number, and the outcome, if any: 6 b. Are you or your children currently receiving public assistance? yes no 6 c. Is Respondent currently employed? yes no 6 d Do any of the children have special costs? ( e.g., tuition, daycare, medical insurance, medical costs; please specify ) American LegalNet, Inc. www.FormsWorkFlow.com 3 7 . Ordering Respondent to vacate my home, which: I rent/own by myself; we rent/own together; I rent/own with someone other than Respondent ( Bring lease/deed to court hearing) 8 . Ordering Respondent to provide me with financial assistance and/or spousal support to pay my rent/mortgage/bills or other expenses. 9 . Awarding possession and use of the follo wing jointly owned property to P etitioner: 10 . Ordering Respondent not to remove me and/or my children from his/her health insurance policy. 11 . Ordering Respondent to reimburse me for medical costs, property damage, or other expenses I have Bring medical bills, receipts, invoices, or estimates to he aring). Damaged property includes ( describe) : 12 . Ordering Respondent to enroll in and complete an appropriate counseling program for: alcohol abuse; drug abuse; domestic violence; par enting; family violence other ( describe) : 13 . Ordering the police to: stand by while Respondent vacates my home: make sure Respondent turns over my keys; accompany me and stand by while I recover my belongings from Respondent; assist me with service of process upon the Respondent. 14 . 15 . Other ( describe) : 16 . danger and I request that the court grant me an emergency Temporary Protecti on Order today. Petitioner further requests any other relief that is appropriate to the effective resolution of this matter, pursuant to D.C. Code Ann 247 16 - 1005(c)(10). Petitioner requests that a hearing be set on this matter and that a Notice of Hearin g and Order to Appear be issued to Respondent. Residence Business DISTRICT OF COLUMBIA, I, , being duly sworn, states that s/he is Petitioner named in this case; that s/he has read and understands the Petition and Affidavit; and that the facts stated are true to the best of her/his knowledge. Date: Petitioner Deputy Clerk/ Office of the Attorney General/ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com