HAR102 State ENG Rev 2/19www.mncourts.gov/formsPage 1 of 6State of Minnesota District Court County of: Select County Judicial District: Court File Number: Case Type: HarassmentIn the Matter of: Petitioner (first, middle, last) On behalf of: Other persons needing protection (first, middle, last) and for her/himselfvs. Respondent (first, middle, last)Petitioner's Affidavit and Petition For Harassment Restraining Order (Minn. Stat. 247 609.748)I understand that I must tell the truth. I state that:1. Petitioner Information (You) Name: (first, middle, last) Date of birth: (month/day/year)Address: I am requesting that my address be kept confidential by submitting the completed Confidential Address/Phone Request form (HAR104) to the court. OR I am not requesting that my address be kept confidential. My address is: My Address: City, State, Zip Code: Phone Number: I am requesting that my phone number be kept confidential by submitting the completed Confidential Address/ Phone Request form (AHAR104) to the court. OR I am not requesting that my phone number be kept confidential. My phone number is: Telephone: American LegalNet, Inc. www.FormsWorkFlow.com HAR102 State ENG Rev 2/19www.mncourts.gov/formsPage 2 of 62. Respondent Information: (person you want protection from) Name: (first, middle, last) Address: Apt. # City State Zip Telephone: Date of birth: (month/day/year) If DOB unknown, age or approximate ageIf Respondent is under 18 years old, their parent or guardian should also be served. If you know information about the parent or guardian, include as much information as possible. Parent or Guardian Name: Parent or Guardian address:3. I am the Petitioner in this case. The victim of the harassment is: me a minor child for whom I am the parent, legal guardian, or stepparent an adult ward for whom I am the legal guardian(If you are the legal guardian of a minor child or adult ward, include a copy of the order appointing you.) The name of each victim and their date of birth, other than me, is: How does each victim know the Respondent and what is their relationship? If you are filing on behalf of another person, what is your relationship to each victim? 4. a) How many restraining orders have been effect, ordering Respondent to stay away from the victims you included at #1 above? none one two or moreFor each restraining order provide: Court File Number, if known County and State where the court is located American LegalNet, Inc. www.FormsWorkFlow.com HAR102 State ENG Rev 2/19www.mncourts.gov/formsPage 3 of 6b) Does Respondent have a current Harassment Restraining Order or Order for Protection against you? Yes, Case File Number (if known) No, I am not aware of any. 5. The following court cases involve me and the Respondent in issues of child custody or parenting time. Court File Number County and State where court is located 6. Respondent has harassed the victim(s) as follows: 267 Check all boxes that apply and give date and details of each incident. 267 To get a Restraining order, you must describe actions that meet the legal definition of harassment in Minnesota. See the Instructions for the definition of harassment. 267 If you need more space, attach a full sheet of paper and continue your description there. Do not write on the back. Respondent physically or sexually assaulted the victim as follows: Respondent has followed, pursued or stalked the victim as follows: Respondent made uninvited visits to the victim as follows: Respondent made harassing phone calls to the victim as follows: Respondent made threats to the victim as follows: Respondent frightened the victim with threatening behavior as follows: Respondent broke into and entered the victim's residence as follows: Respondent damaged the victim's property as follows: American LegalNet, Inc. www.FormsWorkFlow.com HAR102 State ENG Rev 2/19www.mncourts.gov/formsPage 4 of 6 Respondent stole property from the victim as follows: Respondent took pictures of the victim without permission as follows: Respondent shared private sexual images of the victim without permission as follows: Respondent used the victim's personal information, without consent, to invite, encourage, or solicit a third party to engage in a sexual act with the victim as follows: More than once, Respondent has done acts that meet the legal definition of "targetedresidential picketing" by: I told Respondent not to come to certain public events that I or the children attend because: After that, Respondent attended public events I/we attended: (List dates, places, and name of events: These acts by Respondent show a pattern of attending public events while knowing that attending is harassing to me/children. Other: 7. Describe the effect of harassment has upon the victim's safety, security or privacy: 8. Do you believe the harassment will continue? Why? 9. I ask the Court to issue a Restraining Order as follows: Check all boxes (a through e) that apply. a. Respondent shall not harass: me minor children for whom I am the parent, legal guardian, or stepparent an adult ward for whom I am the legal guardian List the full names of everyone included in this Petition: b. Respondent shall have no contact with: me American LegalNet, Inc. www.FormsWorkFlow.com HAR102 State ENG Rev 2/19www.mncourts.gov/formsPage 5 of 6 the minor children listed above an adult ward listed above c. Respondent shall stay away from where I/we live (address) d. Respondent shall stay away from my/the victim's job site located at (address) e. Other: 10. Court HearingPetitioner: Read these Notices about a Hearing 267 You have a right to request a court hearing. Respondent will be served a copy of this Petition if there is a hearing. 267 If the Judge dismisses your case because it has no merit, no hearing will be held. 267 The Judge can issue a Restraining Order without a court hearing if the Judge finds there is immediate and present danger of harassment. 267 If the Judge issues a Restraining Order without a hearing, the Respondent can request a hearing within 20 days of the date the Restraining Order is issued. If Respondent requests a hearing, the court will notify you by mail at least five days before the hearing date. 267 If there is a hearing, you must attend the hearing and prove that the statements in your Petition & Affidavit are true, and that Respondent222s actions are harassment, as defined by Minnesota law. Choose a or b a. I am not requesting a court hearing at this time. b. I am requesting a court hearing. I want I don't want But if the court denies my request for a restraining order because the court finds there is no immediate and present danger of harassment, then (check one) a court hearing.OR11. I request a Restraining Order for a length of: 2 years Until the following date, Up to 50 years because: , which is less than 2 years from today. I have two or more prior restraining orders against Respondent (listed at #2 above.) Respondent has violated prior or existing restraining order between us on two or more occasions. American LegalNet, Inc. www.FormsWorkFlow.com HAR102 State ENG Rev 2/19www.mncourts.gov/formsPage 6 of 6I understand the court will likely schedule a court hearing for any request over 2 years.I declare under penalty of perjury that everything that I have stated in this document is true and correct. Minn. Stat. 247 358.116. Dated: Signature County and State where signed Name: Address: City/State/Zip: Telephone: E-mail address:Notice: If your address or telephone changes, you must give Court Administration your new information right away, in writing. American LegalNet, Inc. www.FormsWorkFlow.com