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 two to five children are involved with this case. Use CP40 for one child and CP41 for six to ten children. Case Number: Judge or Division: Court ORI Number: Petitioner: MSHP Number: Responsible Law Enforcement ORI: Protected Child 1: Related Cases: (Date File Stamp) Age of Protected Child: Protected Child's Relationship to Respondent pursuant to 18 U.S.C. Sex: F M Race: §§ 921(a)(32) and 922(g)(8) determination: Protected Child 2: Protected Child's Relationship to Respondent (Child 1): Age of Protected Child: Child Step-Child or Former Step-Child Parent is Unmarried, Intimate Residing/Resided with Respondent Sex: F M Race: Other (specify) ____________________________________________ Protected Child 3: Age of Protected Child: Sex: F M Race: Protected Child 4: Age of Protected Child: Sex: F M Race: Protected Child 5: Age of Protected Child: Sex: F M Race: vs. Respondent: Alias/Nicknames: Respondent's DOB: Age: SSN (if known, last four digits): Race: Hair Color: Eye Color: Sex: Height: Weight: F M Home Phone Number: Respondent's Work Address: Protected Child's Relationship to Respondent (Child 2): Child Step-Child or Former Step-Child Parent is Unmarried, Intimate Residing/Resided with Respondent Other (specify) ____________________________________________ Protected Child's Relationship to Respondent (Child 3): Child Step-Child or Former Step-Child Parent is Unmarried, Intimate Residing/Resided with Respondent Other (specify) ____________________________________________ Protected Child's Relationship to Respondent (Child 4): Child Step-Child or Former Step-Child Parent is Unmarried, Intimate Residing/Resided with Respondent Other (specify) ____________________________________________ Protected Child's Relationship to Respondent (Child 5): Child Step-Child or Former Step-Child Parent is Unmarried, Intimate Residing/Resided with Respondent Other (specify) ____________________________________________ Respondent's Home Address: (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 Complete questions 1 ­ 7 for each protected child. Protected Child 1: 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. 2. 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. OSCA (03-15) CP42 1 of 7 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. American LegalNet, Inc. www.FormsWorkFlow.com Chapter 455, RSMo 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. 5. 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) _____________________________________________ 6. Respondent has knowingly and intentionally: (check at least one) caused or attempted to cause physical harm to the child sexually assaulted the child placed or attempted to place the child in apprehension of unlawfully imprisoned the child immediate physical harm followed the child from place to place coerced the child threatened to do any of the above stalked the child harassed the child 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) Protected Child 2: 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. 2. 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. 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. There is a prior or pending custody order for this child. 5. 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) _____________________________________________ OSCA (03-15) CP42 2 of 7 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)