STATE OF INDIANA ) ) SS: COUNTY OF ___________ ) IN THE ______________ COURT_____ (____________DIVISION, ROOM ____) CASE NO. __________________________ ________________________________________, Petitioner (Your Name) vs. ________________________________________, Respondent (Person to be Restrained) ) ) ) ) ) PETITION FOR AN ORDER FOR PROTECTION AND REQUEST FOR A HEARING—Filed by Person Seeking Protection IMPORTANT: This is a public document and a copy of it will be placed in the Court’s file. A copy may also be sent to the Respondent. (Check those which apply) 1. I am filing this Petition for myself: ___a. I am or have been a victim of domestic or family violence; ___b. I am or have been a victim of a sex offense; ___c. I am or have been a victim of stalking. 2. The Respondent’s relationship to me is: a. b. c. the Respondent is my family or household member (check only the line which best applies): ___ the Respondent is, or used to be, my spouse; ___ the Respondent and I resided together in an intimate relationship; ___ the Respondent and I have a child in common; ___ the Respondent and I are dating, or have dated, each other; ___ the Respondent and I are, or have been, engaged in a sexual relationship; ___ the Respondent and I are related by blood or adoption. The Respondent is my _________________________; ___ the Respondent and I are, or used to be, related by marriage. The Respondent is my _________________________; ___ the Respondent is, or used to be, my guardian; ___ the Respondent is, or used to be, my ward; ___ the Respondent is, or used to be, my custodian; ___ the Respondent is, or used to be, my foster parent; or, ___ I am a minor child of a person in one of the types of relationships described above. ___the Respondent has committed stalking against me. ___the Respondent has committed a sex offense against me. 1 TCM-PO-0100 Approved 07/02 Rev. by State Ct. Admin. 07/11 American LegalNet, Inc. www.FormsWorkFlow.com 3. How old is the Respondent? ________ years old. 4. Please list all cases (divorce, protection orders, paternity, guardianship, criminal, juvenile, civil) involving the Respondent, yourself, or a child you have with the Respondent (attach additional sheets of paper if necessary): Case Name Case Number County & State __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ _____ Continued on Attachment 4a. 5. This case is filed in this county because: _____ a. the Respondent lives in this county. _____ b. the incident(s) of domestic or family violence, stalking, or the sex offense happened in this county. _____ c. I live in this county. 6. If you are not represented by an attorney, fill in your public mailing address: __________________________________________________________________ __________________________________________________________________ This address will not be kept secret, so you should use a mailing address that you feel comfortable having public. If you want information on how to use the Attorney General’s Address Confidentiality Program, call that office at: 1-800321-1907 to get information on how to participate in that program. 7. The Respondent has committed the following act(s) of domestic or family violence, stalking, or a sex offense (check those which apply): ___ the Respondent attempted to cause physical harm to me; ___ the Respondent threatened to cause physical harm to me; ___ the Respondent did cause physical harm to me; ___ the Respondent placed me in fear of physical harm; ___ the Respondent caused me to involuntarily engage in sexual activity by force, threat of force, or duress; ___ the Respondent committed stalking against me; ___ the Respondent committed a sex offense against me; ___ the Respondent committed an act of animal cruelty by beating, torturing, mutilating, or killing a vertebrate animal without justification with an intent to threaten, intimidate, coerce, harass or terrorize a family or household member. 2 TCM-PO-0100 Approved 07/02 Rev. by State Ct. Admin. 07/11 American LegalNet, Inc. www.FormsWorkFlow.com 8. Describe what happened in each of the above incidents including the date(s), place(s) and witnesses to each incident (attach additional sheets of paper if necessary): Date of Incident #1: ______________ Place of Incident: __________________________________________________ Description of Incident: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ List the names of all of the people who were present during the incident. You must include your own name if you were present: __________________________________________________________________ __________________________________________________________________ Date of Incident #2: ______________ Place of Incident: __________________________ Description of Incident: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ List the names of all of the people who were present during the incident. You must include your own name if you were present: __________________________________________________________________ __________________________________________________________________ Date of Incident #3: ______________ Place of Incident: __________________________ Description of Incident: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ List the names of all of the people who were present during the incident. You must include your own name if you were present: __________________________________________________________________ __________________________________________________________________ _____ Continued on Attachment 8a. 9. I am asking the Court to order the following relief (check all which apply): ___ Prohibit the Respondent from committing, or threatening to commit, acts of domestic or family violence, stalking, or sex offenses against me; ___ Prohibit the Respondent from committing, or threatening to commit, acts of domestic or family violence, stalking, or sex offenses against my family or 3 TCM-PO-0100 Approved 07/02 Rev. by State Ct. Admin. 07/11 American LegalNet, Inc. www.FormsWorkFlow.com household members, whose names are: ___________________________________________________________ __________________________________________________________; ___ Prohibit the Respondent from harassing, annoying, telephoning, contacting, or directly or indirectly communicating with me; ___Order the Respondent to stay away from my residence, school, place of employment, or other place, which is the ___________, located at: _____________________________________________________________; ___Order the Respondent to stay away from the following location(s) frequented by my family or household member(s), which may include a residence, school, or place of employment: __________________________________ _____________________________________________________________ _____________________________________________________________. Please complete: Please list all owners or lease signers at my residence: _____________________ _________________________________________________________________ _________________________________________________________________. NOTE: The following requested relief may be granted immediately by the Judge, but the Court must hold a hearing within thirty (30) days: ___ Evict the Respondent from my residence, which is located at: _____________________________________________________________; ___ Order the Respondent to give me the possession and use of the following: ___The residence located at: ______________________________________; ___An automobile/other motor vehicle described as: ___________________ __________________________________________________________; ___ Other necessary personal items, described as: _____________________ __________________________________________________________ __________________________________________________________; ___Order the following additional relief necessary to provide for my safety and welfare and the safety and welfare of my family or household members: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________. NOTE: The following requested relief may be granted ONLY after notice to the Respondent and at a hearing to be held within thirty (30) days: ___ Specify the arrangements for parenting time with our minor child(ren); ___ Require that parenting time be supervised by a third party; ___ Deny the Respondent parenting time; ___ Order the Respondent to pay my attorney fees; ___ Order the Respondent to pay rent for my residence; ___ Order the Respondent to make payment on a mortgage for my residence; 4 TCM-PO-0100 Approved 07/02 Rev. by State Ct. Admin. 07/11 American LegalNet, Inc. www.FormsWorkFlow.com ___ Order the Respondent to pay child support for our minor child(ren); ___ Order the Respondent to pay support/maintenance for me; ___ Order the Respondent to reimburse me for expenses related to the domestic or family violence, stalking, or sex offense as follows (specify the amount for each expense and bring documentation of the expense with you to Court for the Hearing): ___ Medical expenses: $_________________ ___ Counseling: $_________________ ___ Shelter: $_________________ ___ Repair or replacement of damaged property: $_________________ ___ Other costs or fees I have as a result of bringing this case: $_________________ ___ Prohibit the Respondent from using or possessing a firearm, ammunition, or deadly weapon; ___ Order the Respondent to surrender the following firearm(s), ammunition, or deadly weapon(s) to a specified law enforcement agency (list each item below and attach an additional sheet of paper if necessary): ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________; _____ Continued on Attachment 9a. 10. Number of pages attached: _____ By filing this Petition, I am respectfully requesting that the Court immediately issue an Ex Parte Order for Protection. I understand that, if I have asked the Court for any of the following: • evicting the Respondent from my/our home; • giving me the possession of personal property; • establishing rules for child parenting time; • requiring the Respondent to pay fees, expenses, or child support; • forbidding the Respondent from possessing a firearm, ammunition, or a deadly weapon; or, • ordering the Respondent to surrender firearm(s), ammunition, or deadly weapons, I must also ask the Court to set a date for a Hearing within thirty (30) days of today’s date. I understand that if a Hearing is set, and if I fail to appear for the Hearing, the Court may terminate the Ex Parte Order and dismiss the case. I affirm, under the penalties for perjury, that the foregoing representations are true: a. on the basis of my own personal knowledge. b. on the basis that I have been informed and believe that the facts stated are true. (NOTE: If this Petition is made solely on the basis of 5 TCM-PO-0100 Approved 07/02 Rev. by State Ct. Admin. 07/11 American LegalNet, Inc. www.FormsWorkFlow.com Petitioner’s information and belief, Petitioner must attach affidavits by one or more persons who have personal knowledge of the facts stated.) DATE: _______________ ___________________________________ PETITIONER (Signature) ___________________________________ PETITIONER (Type or print name) 6 TCM-PO-0100 Approved 07/02 Rev. by State Ct. Admin. 07/11 American LegalNet, Inc. www.FormsWorkFlow.com