Print neatly. Use dark ink. You may want to write your answers on scratch paper and then transfer them IN THE IOWA DISTRICT COURT FOR ____________________COUNTY (name of the county where you are filing this petition)_____________________________________________________________________ : : _________________________ : Civil No. ______________________ Plaintiff, :(leave blank - Clerk of Court will fill in) (person desiring domestic : abuse protective order) : vs. : PETITION : : FOR RELIEF FROM _________________________ : DOMESTIC ABUSE Defendant. : (alleged domestic abuser) : : Code Ch. 236____________________________________________________________________________________________ The Plaintiff states: 1. This action is being filed under Iowa Code chapter 236. 2. I (Plaintiff) now live in _______________ County, Iowa. 3. I (Plaintiff) can receive mail at the following address: (any of the following addresses may be used: your mailing address, the mailing address of a shelter or other agency, a public or private post office box, any othermailing address, with permission of the resident of that address) ____________________________________________________________________________ Number, Street City, State Zip Code County4. Defendant lives at the following address (if known): ____________________________________________________________________________ Number, Street City, State Zip Code County5. Defendant works at the following (if known): ____________________________________________________________________ Employer ____________________________________________________________________________ Number, Street City, State Zip Code County6. Is defendant 17 years of age or younger (if known)? No _____ Yes _____ If yes, what is defendants date of birth? / / 7. Give the name and age of each child under age 18 whose welfare may be affected by the controversy. Name Birthdate Name Birthdate _________________ __________ _________________ ____________ _________________ __________ _________________ ____________ _______________ _________ _______________ ___________ 1 >>>> 28. Relationship of plaintiff and defendant at the time of the abuse or threat of abuse:(mark only one box) [ ] Married [ ] Living together [ ] Separated [ ] Lived together within one year [ ] Divorced of the assault, but not at the [ ] Adult relatives living together time of the assault [ ] Parents of the same minor [ ] Intimate relationship* (under 18) child or children [ ] Have been in an intimate relationship and have had contact within one year of the assault * * An intimate relationship means a significant romantic involvement that need not include sexual involvement. An intimate relationship does not include casual social relationships or associations in a business or professional capacity. (NOTE: If none of these boxes accurately describes your relationship, do not completethis form. Contact an attorney and/or call the police about your abuse.)9. Nature of the alleged domestic abuse: (mark all that apply) [ ] Defendant has physically abused me [ ] Defendant has sexually abused me [ ] Defendant has threatened me and I fear for my physical safety10a. Describe the most recent injury, and/or nonconsensual (against your will) sexualexperience, and/or threats. Please include how it happened, where it happened, and whenyou were hurt or threatened: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ b. Describe any other injuries or threats you have received from the defendant. Pleaseinclude how you were hurt or threatened, where it happened and when it happened:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Mark this box [ ] if additional 8 x 11 sheets are attached. 2>>>> 3If the plaintiff and defendant have no children in common (biological or adopted) under age 18, skip questions 11 through 18. Questions 11-18 relate to the Uniform Child-Custody Jurisdiction Act and to the courts duty under Iowa Code 236.5(2)(d) (1993). If you are unsure how to answer thesequestions, contact a lawyer for advice. 11. Who should have temporary custody of the minor children you have in common with the defendant?___ Me (Plaintiff) ___ Defendant ___ Other (please specify) ____________________________12. How will your safety and your childrens safety be affected by the courts decision about temporary custody ortemporary visitation? (please explain) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________13. If you want custody, provide suggestions for how the defendant could visit the children without contacting you --for example, through friends, relatives, or baby-s itters. List concerns you have about visitation:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________14. List the minor children (under age 18) you have in common with the defendant. (Give each childs name, addressand birthdate. If children are living in a shelter or other safe place, give only the county and state where they areliving.) Name Present Address (or county/state) Birthdate_________________________ _________________________________________ _____________________________________________ _________________________________________ _____________________________________________ _________________________________________ _____________________________________________ _______