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. the Respondent is my family or household member (check only the line which best applies): ___ the Respondent is my spouse; ___ the Respondent 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. ___ I have adopted the child of the respondent. 1 TCM-PO-0100 Approved 07/02 Rev. by Ind. Office Ct. Serv. 7/17 American LegalNet, Inc. www.FormsWorkFlow.com b. c. 3. 4. ___the Respondent has committed stalking against me. ___the Respondent has committed a sex offense against me. How old is the Respondent? ________ years old. 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. The address you place on the Confidential Form, PO-0104 will be kept confidential. If the Court grants the order, you may be eligible to obtain a confidential address through the Attorney General's Address Confidentiality Program (ACP). Email the ACP at: confidential@atg.state.in.us to get information on how to participate in that program. 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 2 TCM-PO-0100 Approved 07/02 Rev. by Ind. Office Ct. Serv. 7/17 American LegalNet, Inc. www.FormsWorkFlow.com 7. to threaten, intimidate, coerce, harass or terrorize a family or household member. 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.