Judge Time Hours Minutes CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR Located at City/County Case No. Court Address (NOTE: Fill in the following, checking the appropriate boxes. Petitioners need not give an address if doing so risks further abuse or reveals the confidential address of a shelter. If this is the case, check here If you need additional paper, ask the clerk.) vs. Petitioner Respondent Street Address, Apt. No. Home: Street Address, Apt. No. Home: City, State, Zip Code Work: Telephone Number(s) City, State, Zip Code Work: Telephone Number(s) PETITION FOR PROTECTION FROM DOMESTIC VIOLENCE CHILD ABUSE VULNERABLE ADULT ABUSE 1. I want relief for myself minor child vulnerable adult, from abuse by The Respondent committed the following acts of abuse against on or about, (check all that apply.) Date slapping shooting shoving threats of violence kicking rape or other sexual offense (or attempt) mental injury of a child punching choking/strangling hitting with object detaining against will stabbing stalking biting other The details of what happened are: (Describe injuries. State when and where these acts occurred. Be as specific as you can.): 2. (If the victim is a child or vulnerable adult, fill in the following): I am asking for protection for a child vulnerable adult whose name is At this time the victim can be found at I am State's Attorney DSS a relative an adult living in the home. 3. The person(s) I want protected are (include yourself if you are a victim): Names(s) Birthdate CC-DC/DV 1 (Rev. 10/2011) Page 1 of 3 Relationship to Respondent American LegalNet, Inc. www.FormsWorkFlow.com Case No. vs. Petitioner Respondent 4. the person(s) I want protected now lives, or has lived, with the Respondent for the following period of time during the past year: There are are not additional persons living in the home. 5. I know of the following court cases involving me, or the person I want protected, and the Respondent. (Examples include: paternity, child support, divorce, custody, domestic violence, juvenile cases, criminal cases) Court Kind of Case Year Filed Result or Status (if you know) 6. I have received a final protective order against the same respondent that expired within one (1) year of the abuse alleged in this petition, and which was issued for a period of at least six (6) months. Date issued Date expired Location where issued City/County/State 7. Describe all past injuries the Respondent has caused the victim, and give date, if known 8. The Respondent owns or has access to the following firearms: 9. I want the court to order the Respondent: (NOTE: Petitioner need not give an address if doing so risks further abuse.) NOT to abuse or threaten to abuse Name(s) NOT to contact, attempt to contact, harass Name(s) NOT to go to the residence(s) at Address NOT to go to the school(s) at Name of school and address NOT to go to the child care provider(s) Name of child care provider and address NOT to go to the work place(s) at CC-DC/DV 1 (Rev. 10/2011) Name(s) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case No. vs. Petitioner Respondent To leave the home at Address and give possession of the home to The name(s) on the deed or lease are: To turn over firearm(s) to a law enforcement agency. To go to counseling domestic violence drug/alcohol other To pay money as Emergency Family Maintenance (may be taken from Respondent's paycheck). 10. I also want the Court to order: Custody of Children's names be granted to Name Use and possession of the following jointly-owned vehicle be granted to Name Description of vehicle Temporary possession of the pet(s) Name and Description be granted to Name 11. (Fill in only if you are seeking Emergency Family Maintenance.) The Respondent has the following financial resources: Income from employment in the amount of $ every week 2 weeks month other Source of employment income Name and address of source and amount(s) received Income from other source Name and address of source and amount(s) received The Respondent also owns the following property of value: Automobile(s) $ Estimated Value Home $ Bank Account(s) $ Estimated Value Estimated Value Other: Estimated Value I solemnly affirm under the penalties of perjury that the contents of the foregoing Petition are true to the best of my knowledge, information and belief. -------------------------------------------------------------------------------------------------------- Petitioner Date I have filled in the Addendum (Description of Respondent), CC-DC/DV 1A NOTE If you believe that you have been a victim of abuse and that there is a danger of serious and immediate injury to you, you may request the assistance of a police officer or local law enforcement agency. The law enforcement officer must protect you from harm when responding to your request for assistance and may, if you ask, accompany you to the family home so that you may remove clothing and medicine, medical devices, and other personal effects required for you and your children, regardless of who paid for them. You are entitled to request that address and telephone number of a victim, a complainant, or a witness be considered for shielding at the filing of this application. NOTICE: Remote access to the name, address, telephone number, date of birth, e-mail address, and place of employment of a victim or non-party witness is blocked. (Md Rule 16-1008(a)(3)(B)) CC-DC/DV 1 (Rev. 10/2011) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com