COURT PETITIONER PARISH/CITY OF STATE OF LOUISIANA V. DIVISION: FILED: DEFENDANT NUMBER: CLERK: PETITION FOR TEMPORARY RESTRAINING ORDER, PRELIMINARY AND PERMANENT INJUNCTION Pursuant to La. Code of Civil Procedure Article 3601, et seq. This petition is: G Initial Petition G Supplemental and Amending Petition The petition of ____________________________________, born ______________________, your name month, day, year a resident of the full age of majority of the Parish/City of ________________________, respectfully represents: Paragraph 1 Petitioner files this petition on behalf of: a. ____ Petitioner, and/or b. ____ Minor child(ren) as follows: Name Relationship to petitioner Name DOB Relationship to petitioner Name DOB Relationship to petitioner Name DOB Relationship to petitioner Name DOB Relationship to petitioner Name c. DOB DOB Relationship to petitioner ____ Alleged incompetent: Paragraph 2 a. ____ Petitioner’s current address: No. & Street Apt. No. City b. State Zip Code ____ The minor child(ren)’s or alleged incompetent’s current address: No. & Street Apt. No. City State Zip Code Paragraph 3 ___________________________________________, defendant, resides in ___________________ Parish Abuser’s Name at ___________________________________________________________________________________ No. & Street Apt. No. City State Zip Code LPOR O Page 1 of 5 v.6.1 American LegalNet, Inc. www.FormsWorkFlow.com Paragraph 4 This Court is the proper venue for this action because: The defendant is domiciled in Parish/city. The behavior sought to be enjoined is likely to occur in Parish/city. Other: Paragraph 5 The protected person(s) is related to the defendant as: (check all that apply) ___ ___ ___ ___ Current or former spouse Current or former unmarried intimate cohabitant Child, stepchild, or foster child Child of defendant’s current or former intimate partner ___ ___ ___ ___ Current or former dating partner Parent, stepparent, or foster parent Grandparent or grandchild Other: Paragraph 6 Defendant has abused and/or harassed protected person(s) and protected person(s) fears for her/his safety and believes that irreparable injury, loss, or damage may otherwise result to protected person(s) if defendant is not prohibited from committing certain acts through the rendition of a temporary restraining order, without notice, and thereafter a preliminary and permanent injunction to the same effect. Paragraph 7 a. Defendant abused protected person(s) in the following manner: ___ ___ Threatened protected person(s) with bodily harm ___ Punched protected person(s) ___ Threatened protected person(s)’ life ___ Choked protected person(s) ___ Threatened protected person(s) with a weapon ___ Shoved protected person(s) ___ ___ Kicked protected person(s) Abused petitioner’s child(ren) or alleged incompetent Other: ___ b. Slapped protected person(s) Stalked protected person(s) ___ The facts and circumstances of this abuse are as follows: The most recent incident of abuse which caused petitioner to file this petition happened on or about the day of , , at which time the defendant did Past incidents: LPOR O Page 2 of 5 v.6.1 American LegalNet, Inc. www.FormsWorkFlow.com Paragraph 8 Because of the immediate and present danger of abuse, petitioner requests that an ex parte Temporary Restraining Order be issued immediately without prior notice: a. ____ prohibiting defendant from abusing, harassing, stalking, following, or threatening the protected person(s) in any manner whatsoever. This prohibition includes the use, attempted use, or threatened use of force or physical violence that would reasonably be expected to cause bodily injury. b. ____ prohibiting the defendant from contacting the protected person(s) personally, electronically, by phone, in writing, or through a third party, without the express written permission of this court. c. ____ prohibiting defendant from going within one hundred (100) yards of the residence, apartment complex, or multiple family dwelling of the protected person(s) located at: _______________________________________________________________________ No. & Street d. Apt. No. City State Zip Code ____ ordering the defendant to stay away from the protected person(s)’ place of employment/school and not to interfere in any manner with such employment/school located at: _______________________________________________________________________ Employment/school Address City State Zip Code _______________________________________________________________________ Employment/school e. Address City State Zip Code ____ ordering the defendant not to damage any belongings of the protected person(s), not to shut off any utilities, telephone service, or mail delivery to the protected person(s), or in any way interfere with the living conditions of the protected person(s). Paragraph 9 Petitioner desires that a Rule Nisi issue herein ordering defendant to show cause why the temporary restraining order requested in Paragraph 8 should not be made a preliminary injunction and thereafter a permanent injunction and further why defendant should not be ordered to pay all costs of court in this matter. PRAYER WHEREFORE, petitioner prays that service and citation issue herein, and: (check all that apply) ___ that ex parte temporary restraining order requested in Paragraph 8 be granted. ___ a rule issue to show cause why a preliminary injunction and thereafter a permanent injunction as requested in Paragraph 9 should not be granted. LPOR O Page 3 of 5 v.6.1 American LegalNet, Inc. www.FormsWorkFlow.com ___ defendant be cast with costs. ___ defendant be advised of penalties for violating Abuse Prevention Orders. ___ all other equitable relief as the court deems proper and necessary. Respectfully submitted by, PETITIONER, IN PROPER PERSON ________________________________ Street Address Apt. No. _______________________________________ City State Zip Code ______________________________________ Telephone No. PLEASE SERVE DEFENDANT: personally at his/her home or place of employment at the following address: or LPOR O Page 4 of 5 v.6.1 American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT/VERIFICATION STATE OF LOUISIANA PARISH OF BEFORE ME, the undersigned Notary Public, duly commissioned and qualified in and for the state and parish aforesaid, personally came and appeared _________________________, Petitioner in the foregoing Petition for Temporary Restraining Order, Preliminary and Permanent Injunction, who, after being duly sworn by me, did depose and say that s/he has read the allegations contained therein and declared them to be true and correct to the best of her/his knowledge, information, and belief. Petitioner further said that s/he believes that the defendant poses a threat to petitioner’s safety or to others for whom petitioner has requested relief. Petitioner further said that s/he believes that prior notice should not be required before the court issues the Temporary Restraining Order requested because defendant may further abuse and/or harass petitioner or person on whose behalf this petition is brought before a hearing can be had and an order issued by the court; further, petitioner believes that irreparable injury, loss, or damage will result to her/him or person on whose behalf this petition is brought before defendant can be heard in opposition to petitioner’s request. Petitioner further said that s/he is aware that any false statement made under oath contained in the foregoing petition and this affidavit may constitute perjury. PETITIONER SWORN TO AND SUBSCRIBED before me, Notary Public, on the , 20___, at day of , Louisiana. NOTARY PUBLIC LPOR O Page 5 of 5 v.6.1 American LegalNet, Inc. www.FormsWorkFlow.com