PO-0115 Approved 07-01-02 Revised 07-01-08 STATE OF INDIANA ) ) SS: COUNTY OF ___________ ) IN THE ______________ COURT_____ (____________DIVISION, ROOM ____) CASE NO. __________________________ ________________________________________, Petitioner (Your Name) vs. ________________________________________, Respondent (Person to be Restrained) ) ) ) ) ) PETITION TO MODIFY AN ORDER FOR PROTECTION I am the Petitioner and I swear or affirm, under the penalties for perjury, that the following information is true: 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. The Court has previously issued: ___a. An Ex Parte Order for Protection, on the date of: _______________; or, ___b. An Order for Protection issued after a hearing, on the date of ________________________. 2. The Order described above in Paragraph 1 will expire on the date of ______________________________. 3. I am requesting that the Court modify the Order described above in Paragraph 1 because there has been a substantial change in my circumstances. That change is: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ _________________________________________________________________. 4. Because of the change I described above in Paragraph 3, I am asking the Court to modify the existing Order in the following ways: (check all which apply): ___ Enjoin the Respondent from threatening to commit or committing acts of domestic or family violence, stalking, or sex offenses against the person seeking protection; ___ Enjoin the Respondent from threatening to commit or committing acts of 1 American LegalNet, Inc. www.FormsWorkflow.com PO-0115 Approved 07-01-02 Revised 07-01-08 domestic or family violence, stalking, or sex offenses against these designated family or household members: ___________________________________________________________ __________________________________________________________; ___ Prohibit the Respondent from harassing, annoying, telephoning, contacting, or directly or indirectly communicating with the person seeking protection; ___Order the Respondent to stay away from the protected person’s residence, school, place of employment, or other place frequented by him/her, which is the ___________, located at: _____________________________________; ___Order the Respondent to stay away from the following location(s) frequented by family or household member(s), which may include a residence, school, or place of employment: ________________________________________ __________________________________________________________ __________________________________________________________; NOTE: The following requested relief may be granted immediately, but will require a hearing held within thirty (30) days: ___ Evict the Respondent from the protected person’s residence, which is located at: _____________________________________________; ___ Order the Respondent to give the protected person the possession and use of the following: ___The residence located at: _______________________________; ___An automobile/other motor vehicle described as: ____________ ___________________________________________________; ___ Other essential personal effects, described as: _______________ ____________________________________________________ ____________________________________________________; ___Order the following additional relief necessary to provide for the protected person’s safety and welfare and each of the designated family or household members: _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________. NOTE: The following requested relief may be granted only after notice to the respondent and at a hearing held within thirty (30) days: ___ Specify the arrangements for parenting time with the protected person’s minor child(ren) by the Respondent; ___ Require that parenting time by supervised by a third party; ___ Deny the Respondent parenting time; ___ Order the Respondent to pay the protected person’s attorney fees; ___ Order the Respondent to pay rent for the protected person’s residence; ___ Order the Respondent to make payment on a mortgage for the protected 2 American LegalNet, Inc. www.FormsWorkflow.com PO-0115 Approved 07-01-02 Revised 07-01-08 person’s residence; ___ Order the Respondent to pay child support for minor child(ren)in common with the protected person; ___ Order the Respondent to pay support/maintenance for the protected person; ___ Order the Respondent to reimburse the protected person 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 incurred by the protected person 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 additional sheet of paper if necessary): ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________; By filing this Petition to Modify an Order for Protection, I am respectfully requesting that the Court immediately issue an Ex Parte Order for Protection Modification. I understand that, if I have asked for relief from the Court regarding any of the following: • • • • • • evicting the Respondent from my/our home; awarding 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 respectfully request that the Court set a date for a Hearing within thirty (30) days of today’s date. 3 American LegalNet, Inc. www.FormsWorkflow.com PO-0115 Approved 07-01-02 Revised 07-01-08 I understand that if a Hearing is set, and if I fail to appear for the Hearing, the Court, may dismiss this Petition to Modify. DATE: _______________ ___________________________________ PETITIONER (signed) ___________________________________ PETITIONER (printed) 4 American LegalNet, Inc. www.FormsWorkflow.com