SUPREME COURT OF THE STATE OF NEW YORK 06/27/05COUNTY OF ________________________ county in which divorce is pending ---------------------------------------------------------------x Index No. ______________ insert court index no. Plaintiff, : AFFIDAVIT IN SUPPORT -against- : OF MOTION FOR TEMPORARY RELIEF Defendant. : ----------------------------------------------------------------x STATE OF NEW YORK ) s.s.: COUNTY OF ________________________) where this affidavit is signed I, ____________________________, being duly sworn, depose and say that: your name 1. I am the ______________________ in this action for a divorce. Plaintiff/Defendant 2. I make this affidavit in support of my Motion for Temporary Relief. You may attach copies of any relevant documents in support of your case, please label and refer to them in your affidavit. BACKGROUND FACTS 3. We were married on __________________ in ________________________. date of marriage place of marriage 4. I am ______ years old and my spouse is ______ years old. age age 5. The children of the marriage are: Name of Person Childs Name Date of Birth Social Security No. With Whom Child Resides ________________________________________________________________________ ______ 1 American LegalNet, Inc. www.USCourtForms.com>>>> 2________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ 6. I reside at ________________________________________ and my spouse your address, or if confidential, state a mailing address resides at ______________________________________. spouses address 7. This action for a divorce was commenced on _________________________. A date index number was purchasedcopy of the Summons with Notice is attached as Exhibit A./Action is being commenced simultaneously. (complete the following sections that apply to your situation) REQUEST FOR A TEMPORARY ORDER OF PROTECTION 8. Pending the hearing of the instant application and the further Order of this Court, I request that this Court issue a Temporary Order of Protection which would order __________________________ to remain at least 150 feet away from me, my home spouses name and place of employment, and that ________________________ refrain from assault, stalking, spouses name harassment, menacing, reckless endangerment, disorderly conduct, intimidation, threats or any criminal offense against me and my family by any means, including but not limited to phone calls and other electronic means such as e-mail. 9. I believe I will be awarded an Order of Protection in this case because: (include details with names, dates and places of mental and physical abuse; include the most recent incident, the worstincident and the first incident) ________________________________________________________________________ ______ ________________________________________________________________________ ______ 2 American LegalNet, Inc. www.USCourtForms.com>>>> 3________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ REQUEST FOR A TEMPORARY ORDER OF PROTECTION FOR THE CHILD(REN) 10. Pending the hearing of the instant application and the further Order of this Court, I also request that this Court issue a Temporary Order of Protection which includes protection for my child(ren), and which would order________________________to remain away spouses name from my child(ren), including my child(ren)s home, school, babysitters home, and child care center, and that ______________________ refrain from assault, stalking, harassment, menacing, spouses name reckless endangerment, disorderly conduct, intimidation, threats or any criminal offense against me and my child(ren) by any means, including but not limited to phone calls and other electronic means such as e-mail. 11. The child(ren) to be covered by the Temporary Order of Protection are: Childs Name Date of Birth ____________________________ ______________ ____________________________ ______________ ____________________________ ______________ ____________________________ ______________ 3 American LegalNet, Inc. www.USCourtForms.com>>>> 4____________________________ ______________ 12. I believe I will be awarded an Order of Protection that includes protection for my children in this case because: (include details with names, dates and places of mental and physical abuse; include most recent incident, worst incident and first incident) ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ REQUEST FOR TEMPORARY CUSTODY 13. I should have custody of the following child(ren) of the marriage, while this action is pending because: (identify the child(ren) you seek custody of and describe in detail your relationship with the children and yourinvolvement in caring for and raising the children) ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________