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Adult Abuse-Stalking Petition For Order Of Protection Form. This is a Missouri form and can be use in Circuit Court Statewide.
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Tags: Adult Abuse-Stalking Petition For Order Of Protection, AA40, Missouri Statewide, Circuit Court
IN THE CIRCUIT COURT OF
U OKRUŽNOM SUDU
COUNTY, MISSOURI
OKRUGA, MISSOURI
Case Number: Broj slučaja:
Judge or Division: Sudija ili Odjeljenje:
Court ORI Number: Sudski ORI broj:
Petitioner: Molielj/Moliteljica:
Respondent’s Home Address:
Kućna adresa odgovornog/odgovorne:
Petitioner’s DOB: Datum rodjenja molitelja/moliteljice:
Sex: Spol:
F Ž
Race: Rasa:
M M
vs. Protiv
Respondent: Odgovorni/odgovorna:
Home Phone Number:
Kućni broj telefona:
(Date File Stamp)
(Datum žig dosjea)
Respondent’s Work Address:
Poslovna adresa odgovornog/odgovorne:
Alias/Nicknames: Alias/nadimak:
Respondent’s DOB: Datum rodjenja odgovornog/odgovorne:
Work Phone Number: Poslovni broj telefona:
Work Hours: Radni sati:
SSN (if known): Broj socijalne sigurnosti (ako je poznat):
Other Locations Where Respondent May Be Served:
Druge lokacije gdje odgovorni/odgovorna mogu boraviti:
Race: Rasa:
Sex: Spol:
F Ž
Hair Color: Boja kose:
Age: Starost:
Eye Color: Boja očiju :
Height: Visina:
Hair Length/Style:
Dužina kose/frizura:
Weight: Težina:
M M
Petitioner’s Relationship to Respondent:
Povezanost molitelja/moliteljice sa odgovornim/odgovornom:
Spouse Bračni drug
Ex-Spouse Bivši bračni drug
Unmarried with Child(ren) in Common
Neoženjen/neudata sa zajedničkim djetetom (djecom)
Unmarried, Intimate Residing/Resided Together
Neoženjen/neudata intimno borave/boravili zajedno
Related by Blood/Marriage Srodstvo krvno/bračno
Other (specify) Drugo (specificirati) ___________________
(Identifying Information for use by Law Enforcement)
(Prepoznatljiva informacija za upotrebu od strane organa vlasti)
Visible Identifying Marks (e.g. tattoos, birthmarks, braces, mustache, beard, pierced ear, glasses)
Vidljiva prepoznavajuća obilježja (npr. tetovaže, mladeži, zubna proteza, brkovi, brada, probušeno uho, aočale)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Adult Abuse/Stalking Petition for Order of Protection
Molba za Nalog zaštite protiv zlostavljanja/proganjanja odraslih
I am Petitioner and Ja sam molitelj/moliteljica a
at least 18 years of age najmanje 18 godina star/-a
under 18 but emancipated ispod 18 godina star/-a ali emancipovan
Respondent is odgovorni/odgovorna je
1.
at least 18 years of age najmanje 18 godina star/-a
under 18 but emancipated ispod 18 godina star/-a ali emancipovan/-a
2.
I reside in ___________________ (city), ___________________ (state), in the County of ___________________.
Respondent may be found in ___________________ (city), ___________________ (state), in the
County of ___________________.
Ja boravim u ________________________ (grad), ___________________ (država), u Okrugu ___________________.
Odgovorni/odgovorna boravi u ________________________ (grad), ___________________ (država), u
Okrugu ___________________.
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3.
An act of abuse or stalking occurred at ______________________________________________ (address),
__________________________ (city), ____________ (state), in the County of _____________________________.
Čin zlostavljanja ili proganja dogodio se u ______________________________________________ (adresa)
_________________________ (grad), ____________ (država), u Okrugu _____________________________.
4.
Respondent and I: (check one or more)
Odgovorni/odgovorna i ja: (jedna ili vise kvačica)
are related by blood. smo u krvnom srodstvu.
are spouses. smo supružnici.
were spouses. bili smo supružnici.
have child(ren) in common.
imamo zajedničko dijete (djecu).
are or were residing together.
boravimo ili smo boravilili zajedno.
were related by marriage. bili smo u braku.
are related by marriage. u braku smo.
have no relationship other than Respondent has stalked me.
nismo u vezi sem što me je odgovorni/odgovorna proganjao/proganjala.
are in a continuing romantic or intimate social relationship.
smo u kontinuiranoj romantičnoj ili intimnoj društvenoj vezi.
were in a continuing romantic or intimate social relationship.
bili smo u kontinuiranoj romantičnoj ili intimnoj društvenoj vezi.
Complete for Adult Abuse Petition Only. Popuniti samo za molbu zlostavljanja odraslih.
5. Respondent and I: (check one or more) Odgovorni/odgovornai i ja: (staviti jednu ili vise kvačica)
reside together boravimo zajedno.
previously resided together at ____________________________ (address), ______________________________ (city),
______________________, (state), in the County of _________________________. ranije smo boravili zajedno na
_________________________________________ (adresa), _______________________________________________
(grad), ______________________ (država), u Okrugu _________________________________.
never resided together. nikada nismo boravilili zajedno.
Complete for Stalking Petition Only. Popuniti samo za Molbu proganjanja.
6. Respondent is stalking me. Explain relationship (example: co-workers, neighbors, etc.) Odgovorni/odgovorna me proganja.
Objasniti odnos (primjer: poslovni suradnici, susjedi i sl.)
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Complete for Adult Abuse Petition Only. Popuniti samo za Molbu zlostavljanja odraslih.
7.
The residence in which I live is: (check one or more) Boravak u kojem ja živim je: (Staviti jednu ili više kvačica)
jointly owned, leased or rented or jointly occupied by Respondent and me.
zajednički posjed,iznajmljen ili rentiran ili zajedničko boravište odgovornog/odgovorne i mene.
owned, leased, rented or occupied by me. posjedujem, iznajmljujem ili rentiram ja.
jointly owned, leased, rented or occupied by me and someone other than Respondent.
zajednički posjed, iznajmljen ili rentiran ili zajedničko boravište nekoga drugog ko nije odgovorni/odgovorna i mene.
owned, leased, rented or occupied by someone else, and Respondent is my spouse.
posjeduje, iznajmljuje, rentira ili u njemu boravi neko drugi, a odgovorni/odgovorna je moj supružnik.
jointly occupied by me and another person, and Respondent has no property interest therein.
zajednički boravak mene i druge osobe, a odgovorni/odgovorna nema nikakvih svojinskih interesa u tome.
8.
Respondent has knowingly and intentionally: (check at least one) Odgovorni/odgovorna me je svjesno i namjerno: (staviti bar jednu
kvačicu)
coerced me primoravao me
followed me from place to place pratio me od mjesta do mjesta
stalked me proganjao me
caused or attempted to cause me physical harm
uzrokovao ili pokušao da uzrokuje fizičku povredu
harassed me vrijedjao me
placed or attempted to place me in apprehension of immediate physical harm
sexually assaulted me
izložio ili pokušao da me izloži neposrednoj fizičkoj povredi
seksualno me napada
unlawfully imprisoned me
threatened to do any of the above prijetio da uradi bilo šta od gore navedenog
nezakonito me zatočio
by the following act (s): (Include the most recent date(s) of each act described). Sljedćim činom (činovima): (Uključiti najskoriji datum
(e) svakog čina opisno).
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
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9.
I am afraid of Respondent, and there is an immediate and present danger of abuse or stalking of me because: (describe)
Ja se bojim odgovornog/odgovorne,i postoji za mene neposredna i prisutna opasnost od zlostavljanja i proganjanja zato što: (opisati)
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
10.
Photographs/Exhibits are filed as evidence of my injuries. Fotografije/dokazni materijal priloženi su kao evidencija mojih povreda.
Complete for Adult Abuse Petition Only. Popuniti samo za Molbu zlostavljanja odraslih.
11. It is in the best interest of the minor children that custody be awarded as follows: U najboljem je interesu djeteta da se starateljstvo
odrijedi kako slijedi:
Child’s name
Ime djeteta
DOB
Datum
rodjenja
SSN
Broj socijalne sigurnosti
Age
Starost
Address
(If other than Petitioner)
Adresa
(ako nije ista kao
molitelja/moliteljice)
1.
_________________________________
__________
_______________
____
_____________________________
2.
_________________________________
__________
_______________
____
_____________________________
3.
_________________________________
__________
_______________
____
_____________________________
4.
_________________________________
__________
_______________
____
_____________________________
5.
_________________________________
__________
_______________
____
_____________________________
Who did each Child reside with during
last six months
Sa kim je svako dijete boravilo tokom
poslednjih šest mjeseci
Relationship to Parties
(Explain if not
Respondent’s Child)
Srodstvo sa strankama
(Objasniti ako nije dijete
odgovornog/odgovorne)
Persons to Receive Custody
Osobe kojima se dodjeljuje
starateljstvo
1.
________________________________
________________________
______________________
2.
________________________________
________________________
______________________
3.
________________________________
________________________
______________________
4.
________________________________
________________________
______________________
5.
________________________________
________________________
Custody
(check one or both)
Starateljstvo
(staviti kvačicu na jedan ili oba)
Full
Temporary
Privremeno
Puno
______________________
(If necessary, attach additional sheets.) (Ako je potrebno, priložiti dodatni list)
12. Indicate any prior or pending custody court cases before, or orders entered by, this court or any other court involving the following
parties. (If none, so state): Navesti ma koje prethodne ili nastupajuće sudske slučajeve pred, ili naloge donete, od ovog suda ili bilo kog
drugog suda koji se odnose na sljedeće stranke. (Ako ih nema, tako navedite):
a. Petitioner Molitelj/moliteljica _________________________________________________________________________________
b. Respondent Odgovorni/odgovorna _____________________________________________________________________________
c. Children (identified in item 11) Djeca (identifikovana u stavki 11) ___________________________________________________
13.
Order Petitioner’s residential address on voter’s registration record to be closed to the public. Narediti da adresa
molitelja/moliteljice navedena na glasačkoj kartici bude zatvorena za javnost.
14. 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) Shodno Sekciji 455.010 do Sekcije 455.085 RSMo, zahtjeva se da sud izda Ex Parte
jednostrani Nalog zaštite zabranjujući odgovornom/odgovornoj da: (staviti kvačicu za sve što je primenljivo)
abusing, threatening to abuse, molesting or disturbing the peace of Petitioner wherever Petitioner may be found. zlostavljanje,
prijetnju zlostavljanjem, narušavanje ili remećenje mira molitelja/moliteljice gde god da se molitelj-moliteljica može naći
stalking Petitioner. proganjanje molitelja/moliteljice.
entering the dwelling of Petitioner located at (see notice below) ulaženje u boravak molitelja/moliteljice sa lokacijom (vidjeti
Bilješku ispod) ____________________________________________________________________________________________
communicating with Petitioner in any manner or through any medium. komuniciranje sa moliteljom/moliteljicom u bilo kom vidu
illi putem bilo kog medija.
other: drugo: ____________________________________________________________________________________________
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15. It is further requested that, upon the hearing of this cause, the court issue an Order of Protection enjoining Respondent from the above
acts for such time as is necessary to protect Petitioner and that the court: (one or more may be selected) Dalje se zahtjeva da, po
saslušanju ovog slučaja, sud izda Nalog o zaštiti zabranjujući odgovornom/odgovornoj gore navedene činove i za onoliko vrijemena
koliko je potrebno da zaštiti molitelja/moliteljicu i da sud: (može se izabrati jedan ili više)
Award custody of the minor child(ren) to
Petitioner
Respondent.
Dodjeljuje starateljstvo maloletnog djeteta (djece)
Molitelju/moliteljici
Odgovornom/odgovornoj.
Order visitation with the minor child (ren) to
Petitioner
Respondent as follows:
Odredi posjetu sa maloletnim djetetom (djecom)
Molitelju/moliteljici
Odgovornom/odgovornoj kako slijedi:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Order
Petitioner
Respondent to pay child support to
Petitioner
Respondent in the amount of $ _____________ (check
one)
per week
per month. Naredi
Molitelju/moliteljici
Odgovornom/odgovornoj da plaća izdržavanje djeteta
Odgovornom/odgovornoj u iznosu od $ _____________ (kvačica na jedno)
sedmično
mjesečno.
Molitelju/moliteljici
Order
Petitioner
Respondent to pay maintenance to
Petitioner
Respondent in the amount of $ _____________ (check
per week
per month.
one)
Naredi
Molitelju/moliteljici
Odgovornom/odgovornoj da plaća izdržavanje
Molitelju/moliteljici
Odgovornom/odgovornoj u iznosu od $ _____________ (kvačica na jedno)
sedmično
mjesečno.
Order that Respondent make or continue to make the rent or mortgage payments in the amount of $ ______________ on the residence
occupied by Petitioner. Naredi da odgovorni/odgovorna vrši ili nastavi da vrši uplate rente ili hipoteke u iznosu od $___________ za
boravište u kojem boravi molitelj/moliteljica.
Order that Respondent pay Petitioner’s rent at a residence, other than the residence previously shared with Respondent, in the
amount of $ _______________. Naredi da odgovorni/odgovorna plaća molitelju/moliteljici rentu za boravište drugo od boravišta
koje je prije dijelio/dijelila sa odgovornim/odgovornom u iznosu od $________________.
Order that Petitioner be given temporary possession of the following personal property: Naredi da se molitelju/moliteljici
privremeno dozvoli posjedovanje sljedeće lične svojine:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Prohibit Respondent from transferring, encumbering, or otherwise disposing of the following property mutually owned or leased
with Petitioner: Zabrani odgovornom/odgovornoj da prenese, zaduži ili drugačije raspolaže sa sljedećom svojinom zajednički
posjedovanom ili iznajmljivanom sa moliteljem/moliteljicom: ______________________________________________________
_______________________________________________________________________________________________________
Order Respondent to participate in a court-approved counseling program designed to help batterers stop violent behavior. Naredi
odgovornom/odgovornoj da sudjeluje u sudski odobrenom savjetodavnom programu dizajniranom da pomogne prestupnicima da
prestanu sa nasilnim ponašanjem.
Order Respondent to pay a reasonable fee for housing and other services provided to Petitioner by a shelter for victims of domestic
violence. Naredi odgovornom/odgovornoj da plaća razumnu naknadu za boravak i druge usluge koje molitelju/moliteljici
obezbjedjuje sklonište za žrtve domaćeg nasilja.
Order Respondent to pay the cost of medical treatment or services provided to Petitioner as a result of injuries sustained by an act
of domestic violence committed by Respondent. Naredi odgovornom/odgovornoj da plaća usluge medicinskog liječenja ili usluge
koje se pružaju molitelju/moliteljici kao rezultat povreda nanijetih činom domaćeg nasilja koje je počinio odgovorni/odgovorna.
Order Respondent to pay court costs. Naredi odgovornom/odgovornoj da plati troškove suda.
Order Respondent to pay Petitioner’s attorneys fees. Naredi odgovornom/odgovornoj da plati advokatske naknade
molitelja/moliteljice.
Other (specify): Drugo (specificirati): _________________________________________________________________________
I swear/affirm under penalty of perjury that these facts are true according to my best knowledge and belief. Zaklinjem se/potvrdjujem
pod prijetnjom kazne da su ove činjenice istinite prema mom najboljem znanju i uvjerenju.
______________________________________________________
Date Datum
______________________________________________________
Petitioner’s Signature Potpis molitelja/moliteljice
______________________________________________________
Address (Optional)Adresa (Opciono)
NOTICE:
Section 455.030.3 RSMo provides that a
Petitioner seeking protection under the Adult Abuse Act
is not required to reveal any current address or place of
residence on this motion. Do not provide this
information if doing so will endanger you.
BILJEŠKA: Sekcija 455.030.3 omogućava da se od
molitelja/moliteljice koji/koja traži zaštitu zbog čina
zlostavljanja odraslih ne zahtjeva da otkrije nijednu
tekuću adresu ili mjesto prebivanja u ovom postupku.
Nemojte davati ovu informaciju ako bi vas to ugrozilo.
______________________________________________________
City, State and Zip Grad, država, poštanski broj
______________________________________________________
Telephone Telefon
______________________________________________________
Attorney’s Name, Missouri Bar No., if Applicable
Ime advokata Missoury Bar br., ako je primenljivo
______________________________________________________
Address Adresa
______________________________________________________
City, State and Zip Grad, država, poštanski broj
______________________________________________________
Telephone Telefon
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Definition of Abuse
Definicija zlostavljanja
You are notified that under Section 455.010 (1) RSMo the term “abuse” includes, but is not limited to: Vi ste obaviješteni da po Sekciji
455.010 (1) RSMo termin “zlostavljanje” uključuje, ali nije i ograničeno, na:
1. the occurrence of, or dogadjaj, ili
2. attempt to do, or pokušaj da se uradi, ili
3. threats to do any of the following acts against Petitioner: prijetnje da se uradi bilo koje od sljedećih dijela protiv molitelja/moliteljice:
(a) purposely or knowingly placing or attempting to place Petitioner in fear of physical harm; namjerno ili svjesno stavljanje ili pokušaj
stavljanja molitelja/moliteljice u strah od fizičke povrede;
(b) purposely or knowingly causing physical harm to Petitioner with or without a deadly weapon; namjerno ili svjesno uzrokujući fizičke
povrede molitelju/moliteljici sa ili bez smrtonosnim oružjem;
(c) compelling Petitioner by force or threat of force to engage in conduct from which Petitioner has a right to abstain or to abstain from
conduct in which Petitioner has a right to engage; primoravanje silom molitelja/moliteljice da se učestvuje u ponašanju od kakvog
molitelj/moliteljica ima pravo da se suzdrži ili suzdrži od ponašanja od kojeg molitelj/moliteljica ima pravo da se angažuje;
(d) engaging in a purposeful or knowing course of conduct involving more than one incident that alarms or causes distress to Petitioner and
serves no legitimate purpose. The course of conduct must be such as would cause a reasonable adult to suffer substantial emotional
distress and must actually cause substantial emotional distress to Petitioner. Such conduct might include, but is not limited to:
učestvovanje u ponašanju namjerno ili svjesno uključujući više od jednog incidenta koje uznemiruje ili uzrokuje nevolju
molitelju/moliteljici i ne služi nikakvoj zakonskoj namjeri. Tok ponašanja mora biti takav da bi izazvao normalnu odraslu osobu da
pati od suštinske emotivne nevolje i mora uistinu izazvati suštinsku emotivnu nevolju kod molitelja/moliteljice.Takvo ponašanje može
uključiti, ali nije ograničeno na:
a. Following Petitioner about in a public place or places; Praćenje molitelja/moliteljice na javnom mjestu ili mjestima;
b. Peering in the window or lingering outside the residence of Petitioner; Virenje kroz prozor ili zadržavanje van rezidencije
molitelja/moliteljice;
(e) causing or attempting to cause Petitioner to engage involuntarily in any sexual act by force, threat of force, or duress; or uzrokovanje
ili pokušaj uzrokovanja da molitelj/moliteljica bezvoljno i silom učestvuje u bilo kojem seksualnom aktu, prijetnja silom, ili prinudom;
ili
(f) holding, confining, detaining, or abducting Petitioner against Petitioner’s will. držanje, pritvor, zadržavanje, ili otmicu
molitelja/moliteljice protiv volje molitelja/moliteljice.
Definition of Stalking
Definicija proganjanja
You are notified that, under Section 455.010 (10) RSMo, “stalking” occurs when an adult purposely and repeatedly engages in an
unwanted course of conduct that could cause alarm to a reasonable person. “An unwanted course of conduct” is behavior that serves no legitimate
purpose. Such conduct may include following a person or unwanted communication or contact. “Repeated” means two or more incidents that show a
continuity of purpose, in other words, that are intended to cause alarm. “Alarm” means fear of physical harm. Vi ste obaviješteni da po Sekciji
455.010 (10) RSMo, “proganjanje” nastaje kada je odrasla osoba namjerno i ponovljeno angažovana u neželjeni tok ponašanja koji bi mogao
uzrokovati uzbunu kod razumne osobe. “Neželjeni tok ponašanja” je ophodjenje koje ne služi legitimnoj namjeri. Takvo ponašanje može uključiti
praćenje osobe ili neželjenu komunikaciju ili kontakt. “Ponovljeno” znači dva ili više incidenta koji pokazuju kontinuitet namjere, drugim riječima,
sa namjerom da uzrokuju uzbunu. “Uzbuna” znači strah od fizičke povrede.
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