IN THE _____ JUDICIAL CIRCUIT COURT, ____________________________, MISSOURI Petition for Order of Child Protection Notice to Petitioner: Respondent will receive a copy of this petition with service. Use this form when one child is involved with this case. Use CP42 for two to five children and CP41 for six to ten children. Case Number: Judge or Division: Court ORI Number: Petitioner: MSHP Number: Responsible Law Enforcement ORI: Related Cases: (Date File Stamp) Protected Child: Protected Child's Relationship to Respondent pursuant to 18 U.S.C. Age of Protected Child: §§ 921(a)(32) and 922(g)(8) determination: Sex: F M Race: Protected Child's Relationship to Respondent: vs. Child Step-Child or Former Step-Child Respondent: Parent is Unmarried, Intimate Residing/Resided with Respondent Other (specify) ____________________________________________ Alias/Nicknames: Respondent's Home Address: Respondent's DOB: Age: SSN (if known, last four digits): Race: Sex: F M Home Phone Number: Hair Color: Height: Respondent's Work Address: Eye Color: Weight: (Identifying Information for use by Law Enforcement) Visible Identifying Marks (e.g., tattoos, birthmarks, braces, mustache, beard, pierced ear, glasses): Work Phone Number: Work Hours: Other Locations Where Respondent May Be Served: I. PROTECTED CHILD INFORMATION 1. I am Petitioner and the: (check appropriate boxes) parent or guardian of the child. guardian ad litem for the child. court appointed special advocate for the child. juvenile officer. Respondent is: a household member who is residing with the child. a household member who resided with the child in the past. an emancipated child who is residing with the child. an emancipated child who resided with the child in the past. stalking the child. a household member under 17 who is residing with the child. a household member under 17 who resided with the child. a person under 17 stalking the child. 2. 3. The act(s) of domestic violence or stalking occurred at ______________________________________ (address) ________________________ (city) ___________________________________ (County/City of St. Louis), Missouri. 3.a. The county in which this petition is being filed is where the protected child lives respondent may be act(s) of domestic violence or stalking occurred. (check appropriate boxes) served 4. There are no prior or pending custody orders for this child. There is a prior or pending custody order for this child. The family home of the child is: (check appropriate boxes) owned leased rented By: Respondent Petitioner Other (name) __________________________________ Occupied by: (include name only if different from above) _____________________________________________ 5. OSCA (03-15) CP40 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Chapter 455, RSMo 6. Respondent has knowingly and intentionally: (check at least one) caused or attempted to cause physical harm to the child placed or attempted to place the child in apprehension of immediate physical harm coerced the child stalked the child harassed the child sexually assaulted the child unlawfully imprisoned the child followed the child from place to place threatened to do any of the above by the following acts: (Include the most recent date(s) of the acts described.) 7. An immediate and present danger of domestic violence or stalking to the child exists because: (describe) II. RESPONDENT INFORMATION 8. Respondent is at least 17 years of age or emancipated under 17 9. Respondent may be found in ________________________________________ (city), ________________________ (state), in the County of _____________________________. III. CUSTODY The court cannot change custody if a prior order regarding custody is pending or has been made. 10. It is in the best interest of the child that custody be awarded as follows: Child's Name Relationship to Parties Person to Receive Custody Temporary Full ______________________ _________________________ _______________________ 11. 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): a. Petitioner: _________________________________________________________________________ b. Respondent: _______________________________________________________________________ c. 12. Child (identified in item ): ___________________________________________________________ Award visitation with the child as follows: IV. PETITIONER'S REQUESTS 13. Pursuant to chapter 455, RSMo, it is requested that the court issue an Ex Parte Order of Protection restraining Respondent from: (check boxes that apply) Committing or threatening to commit domestic violence, stalking, molesting, or disturbing the peace of the protected child). Having any contact with the protected child, except as specifically authorized by this Order. Entering the family home of the protected child, located at ____________________________________. Entering the place of employment or school of the protected child, located at _____________________. Communicating with the protected child in any manner or through any medium. Come within ____________ (feet) of the protected child. Other: OSCA (03-15) CP40 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Chapter 455, RSMo 14. · · · · 15. It is further requested that the Ex Parte Order of Protection exclude Respondent from the family home of the protected child because: It is in the best interest of the child remaining in the home; A substantial risk to the child exists unless Respondent is excluded; A remaining adult family or household member is able to care adequately for the child in the absence of Respondent; and A commitment has been obtained from the Children's Division to provide appropriate social services to the family or household members during the period of time during which an Order of Protection is in effect. Exclusion of the Respondent from the family home of the protected child is not being requested. Additional Requests: 16. It is further requested that, upon the hearing of this cause, the court also issue a Full Order of Child Protection enjoining Respondent from the above acts for such time as is necessary to protect the protected child and that the court: Order Respondent not to commit or threaten to commit domestic violence, stalk, molest, or disturb the peace of the protected child. Order Respondent not to have any contact with the protected child(ren), except as specifically authorized