IN THE _____ JUDICIAL CIRCUIT COURT, ___________ _______________, MISSOURI Adult Abuse/Stalking Petition for Order of Protection Notice to Petitioner: Respondent will receive a copy of this petition with service. Judge or Division: Petitioner: vs. Respondent: Alias/Nicknames: Home Phone Number: Respondent's Work Address: Case Number: Court ORI Number: MSHP Number: Responsible Law Enforcement ORI: Related Cases: Respondent's Home Address: (Date File Stamp) Respondent's DOB: Age: SSN (if known, last four digits): Race: Hair Color: Eye Color: Sex: F Height: Weight: M Work Phone Number: Work Hours: Other Locations Where Respondent May Be Served: (Identifying information for use by Law Enforcement) Visible Identifying Marks (e.g. tattoos, birthmarks, braces, mustache, beard, pierced ear, glasses): Petitioner's Relationship to Respondent pursuant to 18 U.S.C. §§ 921(a)(32) and 922(g)(8) determination: Spouse Child(ren) in common Former spouse Intimate residing/resided together Are/were in a continuing social relationship of a romantic/intimate nature Related by blood. Define relationship: Related by marriage. Define relationship: Residing/resided together; no intimacy Stalking. Define relationship: I. PETITIONER INFORMATION 1. 2. I am Petitioner and at least 17 years of age under 17 but emancipated I reside in _______________________________________________ (city), ______________________________ (state), in the County of _____________________________. II. RESPONDENT INFORMATION 3. 4. Respondent is at least 17 years of age or emancipated under 17 Respondent may be found in ________________________________________ (city), ________________________ (state), in the County of _____________________________. III. LOCATION WHERE DOMESTIC VIOLENCE OR STALKING OCCURRED 5. An act of domestic violence or stalking occurred at _________________________________________________________ (address), _______________________________ (city), _____________ (state), in the County of ______________________________. OSCA (03-15) AA40 (ASPO) 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 455.010, 455.030, 455.030.3 RSMo IV. COMPLETE FOR DOMESTIC VIOLENCE PETITION ONLY Relationship with Respondent 6. Respondent and I: (check one or more) reside together. previously resided together at ________________________________________________________________ (address), _________________________________________________ (city), _____________________________ (state), in the County of _______________________________________. never resided together. Residency 7. The residence in which I live is: (check one or more) jointly owned, leased or rented or jointly occupied by Respondent and me. owned, leased, rented or occupied by me. jointly owned, leased, rented or occupied by me and someone other than Respondent. owned, leased, rented or occupied by someone else, and Respondent is my spouse. jointly occupied by me and another person, and Respondent has no property interest therein. Custody List only the children that the Petitioner and Respondent have in common. The court cannot change custody if a prior order regarding custody is pending or has been made. 8. It is in the best interest of the minor children that custody be awarded as follows: Child's Name 1. 2. 3. 4. 5. ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ SSN (last 4 digits only) _______________ _______________ _______________ _______________ _______________ Age _____ _____ _____ _____ _____ Address (If other than Petitioner) ________________________ ________________________ ________________________ ________________________ ________________________ Custody Who did each Child reside with during last six months 1. 2. 3. 4. 5. ______________________ ______________________ ______________________ ______________________ ______________________ Persons to Receive Custody _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ (check one or both) Temporary Full (If necessary, attach additional sheets.) V. COMPLETE FOR STALKING PETITION ONLY 9. Respondent is stalking me. Explain relationship (example: co-workers, neighbors, etc.) VI. COMPLETE FOR ALL CASES 10. Indicate any prior or pending custody court cases before, or orders entered by, this court or any other court involving the following parties. Indicate the case numbers. (If none, so state): a. Petitioner _______________________________________________________________________________________ b. Respondent _____________________________________________________________________________________ c. Children (identified in item 9) ________________________________________________________________________ OSCA (03-15) AA40 (ASPO) 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 455.010, 455.030, 455.030.3 RSMo Domestic Violence/Stalking Acts Committed by Respondent: 11. Respondent has knowingly and intentionally: (check at least one) caused or attempted to cause me physical harm placed or attempted to place me in apprehension of immediate physical harm coerced me stalked me harassed me sexually assaulted me unlawfully imprisoned me followed me from place to place threatened to do any of the above by the following act(s): (Include the most recent date(s) of each act described.) 12. I am afraid of Respondent and there is an immediate and present danger of domestic violence to me or other good cause for an emergency temporary order of protection because: (describe) 13. Photographs/Exhibits are filed as evidence of my injuries. VII. PETITIONER'S REQUESTS 14. Order Petitioner's residential address on voter's registration record to be closed to the public. 15. Pursuant to section 455.010 to section 455.085 RSMo, it is requested that the court issue an Ex Parte Order of Protection restraining Respondent from: (check all that apply) committing or threatening to commit domestic violence, molesting or disturbing the peace of Petitioner wherever Petitioner may be found. stalking Petitioner. entering the dwelling of Petitioner located at (see notice below) ___________________________________________ ______________________________________________________________________________________________ entering the premises of the Petitioner's school, located at ____________________________________________