FCA §154-d; CPL §§530.12 (3),(3-a),(3-b) (Local Criminal Court): County of _________________________________ Petitioner Family Court General Form 5b Criminal Form 3 12/2013 -against- Respondent. _______________________________________ State of New York ) ): ss: County of ) AFFIDAVIT IN SUPPORT OF ISSUANCE OF FAMILY COURT TEMPORARY ORDER OF PROTECTION (By Individual Complainant/Petitioner) Index/Docket # I, (petitioner's name)1 ___________________________________, having been duly sworn, depose and state the following under the penalties of perjury: 1. The Family Court, County, is not in session at the present time. 2. The following family offense was committed on (specify date): ________ by the abovenamed Respondent [Check box or boxes]: " Disorderly conduct " Menacing in the second or third degree " Harassment in the first or second degree " Reckless endangerment " Assault in the second or third degree " Aggravated harassment in the second degree " Attempted assault in second or third degree " Stalking " Criminal mischief " Sexual misconduct " Forcible touching " Sexual abuse in the second2 or third degree " Strangulation " Criminal obstruction of breathing or circulation st nd rd " Identity theft in 1 , 2 or 3 degree " Grand larceny in 3rd or 4th degree nd " Coercion in 2 degree [Penal Law §135.60 (1),(2),or (3) 3. The Respondent and I are related as follows: " " " " we are married " we were married we have a child in common " we are parent & child we are related by blood or marriage [specify how]: we are in an intimate relationship (NOT casual social or business acquaintances) NOTE: If the Petitioner is a peace or police officer, representative of a duly authorized agency or other person designated by the Court to file a petition pursuant to Family Court Act §822, Family Court General Form 5c/ Criminal Form 4 should be used instead of this form. 2 1 Where victim is incapable of consent for reason other than being under age 17 [Penal Law §130.60(1)]. American LegalNet, Inc. www.FormsWorkFlow.com Family Court General Form 5b/Crim 3 Page 2 [describe]: " we were in an intimate relationship (NOT casual social or business acquaintances)[describe]: 4. [Check one]: " I filed a petition under Article 8 of the Family Court Act in Family Court,__________County, on [specify date]:__________. " I intend to file a petition in Family Court, County, on the next day the Court is in session. 5. The following constitutes good cause for issuing a temporary order of protection:[Briefly describe family offense and any other facts and reasons supporting the need to protect me, my child(ren) or other members of my family or household]: 6.a. The following criminal, matrimonial or Family Court cases have been filed involving the respondent and me: [Specify type of case, who filed it, the court in which it was filed, the approximate date filed and the present status, if known]: b. The following orders of protection or temporary orders of protection have been issued against the respondent or against me: [Specify type of case in which the order was issued, persons protected by the order, the court that. issued it, the approximate date issued and expiration date, if known]: 7. I understand that the Family Court order issued by this Court shall expire on the date indicated on the order, which shall be not more than four calendar days after its issuance, unless sooner vacated or modified by the Family Court. I understand that the matter will be transferred to the Family Court and that I must appear in Family Court on or before the date indicated. I further understand that I have a right to seek a criminal prosecution of respondent in addition to, or instead of, proceeding in Family Court. WHEREFORE, for the reasons stated above, I am requesting that my application for a Family Court temporary order of protection be granted and that the matter be transferred to the Family Court, ________________ County. False statements in this affidavit are punishable as a class A misdemeanor, pursuant to Penal Law §210.45. Sworn to before me this day of __________________________ (JUDGE): (SUPERIOR OR DESK OFFICER, POLICE DEPARTMENT): (NOTARY PUBLIC): TO THE CLERK OF COURT: This affidavit, together with any temporary order of protection so issued, shall be transmitted forthwith to the Family Court; if the affidavit and order are transmitted by facsimile or other electronic means, the original shall be forwarded immediately thereafter. ________________________ Petitioner American LegalNet, Inc. www.FormsWorkFlow.com