AOC-275.1 Doc. Code: COM Rev. 1-16 Page 1 of 3 Commonwealth of Kentucky Court of Justice www.courts.ky.gov KRS Chapter 403; KRS Chapter 456; FCRPP Part IV Case No. Court ____________________ ____________________ County Division PETITION/MOTION FOR ORDER OF PROTECTION PETITIONER First Middle Last (check one or both if applicable) q Petitioner filing on his/her own behalf q Petitioner filing on behalf of minor identified on Page 2 VS. RESPONDENT First Middle Last Information about Respondent: Current Residence: ________________________________________________________________________________ Usual Residence: _________________________________________________________________________________ Occupation: _________________________________________________________________________________ Employer Name: _________________________________________________________________________________ Employer Address: ________________________________________________________________________________ School/Postsecondary Institution (if currently attending): _____________________________________________________ Address: _________________________________________________________________________________________ Sex Race Birthdate Height Weight Eyes Hair Social Security # Drivers License # State Exp. Date q Weapon involved q Believed to be armed and dangerous CAUTION: Petitioner and Respondent are involved in a q divorce q custody q visitation case in _____________________ Court. Petitioner says that on _________________, 2____, in ____________________County, Kentucky, the above-named Respondent engaged in act(s) of domestic violence and abuse, dating violence and abuse, stalking, or sexual assault in that*: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ * If additional space is needed please use a separate sheet of paper and attach to the Petition/Motion. Copies to: Court File Respondent (copy with blacked-out portion served with summons) Court Clerk in County of Petitioner's usual residence, if different Law enforcement agency/dispatch responsible for LINK entry Petitioner Local Department of Community Based Services, CHFS Law enforcement agency(ies) designated for service ENSURE ENTRIES IN BOXES ARE COMPLETE, ACCURATE AND LEGIBLE TO ALLOW PROMPT ENTRY INTO LINK IF ORDER OR SUMMONS ISSUES, AND TO ENABLE THE COURT TO OBTAIN RESPONDENT'S DOMESTIC VIOLENCE AND CRIMINAL HISTORY. American LegalNet, Inc. www.FormsWorkFlow.com AOC-275.1 Rev. 1-16 Page 2 of 3 Case No.______________________ 1. Information about Petitioner or minor (if filing on behalf of a minor): Name: ________________________________________________ Birthdate: _________________ Age: ______ Usual Residence: _________________________________________________________________________________ Directions for rural areas: ___________________________________________________________________________ ____________________________________________________________ Length of residence there: ______________ Current Residence (if different from above): ______________________________________________________________ Directions for rural areas: ___________________________________________________________________________ ____________________________________________________________ Length of residence there: ______________ Occupation: ______________________________________________________________________________________ Employer Name: __________________________________________________________________________________ Employer Address: ________________________________________________________________________________ School/Postsecondary Institution (if currently attending): ____________________________________________________ Address: ________________________________________________________________________________________ 2. Respondent's relationship to Petitioner: q married; q formerly married; q unmarried, with child in common; q unmarried, currently or formerly living together; q parent; q child; q stepparent; q grandparent; q grandchild; q person who lives in the same household as a child(ren) if the child(ren) is the alleged victim (specify): ____________________________________________________________________________________________ q currently or previously in a dating relationship. A "dating relationship" means a relationship of a romantic or intimate nature. Length of the relationship, frequency and type of interaction between the Petitioner and Respondent may be considered. q none of the above relationships apply, but Respondent is alleged to have committed q stalking or q sexual assault 3. If Petitioner and Respondent have minor children, complete the following: Name Birthdate Address Parent is q Pet. q Resp. Are you seeking protection for this child? q Yes q No q Pet. q Resp. q Yes q No q Pet. q Resp. q Yes q No q Pet. q Resp. q Yes q No q Pet. q Resp. q Yes q No q Pet. q Resp. q Yes q No American LegalNet, Inc. www.FormsWorkFlow.com AOC-275.1 Rev. 1-16 Page 2 of 3 Case No.______________________ 1. Information about Petitioner or minor (if filing on behalf of a minor): Name: ________________________________________________ Birthdate: _________________ Age: ______ Usual Residence: ____________