FORM 10.01-D: PETITION FOR DOMESTIC VIOLENCE CIVIL PROTECTION ORDER COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS BUTLER COUNTY, OHIO Petitioner : Case No. Address : Judge City, State, Zip Code : Date of Birth: : PETITION FOR DOMESTIC VIOLENCE CIVIL PROTECTION ORDER (R.C. 3113.31) : v. : Notice to Petitioner: Throughout this form, check every that applies. Respondent : Address : City, State, Zip Code Date of Birth: DO NOT WRITE YOUR ADDRESS ON THIS FORM IF YOU ARE REQUESTING CONFIDENTIALITY. PLEASE PROVIDE AN ADDRESS WHERE YOU CAN RECEIVE NOTICES FROM THE COURT. : 1. Petitioner is a family or household member of Respondent and a victim of domestic violence and seeks relief on Petitioner’s own behalf. The relationship of Petitioner to Respondent is that of: Spouse of Respondent Former spouse of Respondent The natural parent of Respondent’s child Other relative (by blood or marriage) of Respondent/ Petitioner who has lived with Respondent at any time Child of Respondent Parent of Respondent Foster Parent Person “living as a spouse of Respondent” defined as: • now cohabiting; • or cohabited within five years before the alleged act of domestic violence 2. Petitioner seeks relief on behalf of the following family or household members: NAME DATE OF BIRTH HOW RELATED TO PETITIONER RESPONDENT RESIDES WITH 3. Respondent has engaged in the following act(s) of domestic violence (describe the acts as fully as possible, add additional pages if necessary): FORM 10.01-D: PETITION FOR DOMESTIC VIOLENCE CIVIL PROTECTION ORDER Amended: July 1, 2010 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Page 4 of Form 10.01-D] 4. Petitioner requests that the Court grant relief under R.C. 3113.31 to protect the Petitioner and or the family or household members named in this Petition from domestic violence by granting a civil protection order that: (a) Directs Respondent not to abuse Petitioner and the family or household members named in this Petition by harming, attempting to harm, threatening, following, stalking, harassing, forcing sexual relations upon them, or by committing sexually oriented offenses against them. (b) Requires Respondent to leave and not return to or interfere with the following residence and grants Petitioner exclusive possession of the residence: (c) Divides household and family personal property and directs Respondent not to remove, damage, hide, or dispose of any property or funds that Petitioner owns or possesses. (d) Temporarily allocates parental rights and responsibilities for the care of the following minor children and suspends Respondent’s visitation rights until a full hearing is held (include names and birth dates of the minor children): (e) Establishes temporary visitation rights with the following minor children and requires visitation to be supervised or occur under such conditions that the Court determines will insure the safety of Petitioner and the minor children (include names and birth dates of the minor children): (f) Requires Respondent to provide financial support for Petitioner and the other family or household members named in this Petition. (g) Requires Respondent to complete batterer counseling, substance abuse counseling, or other counseling as determined necessary by the Court. (h) Requires Respondent to refrain from entering, approaching, or contacting (including contact by telephone, fax, e-mail, and voice mail) the residence, school, business, and place of employment of Petitioner and the family or household members named in this Petition. (i) Requires Respondent to permit Petitioner or other family or household member to have exclusive use of the following motor vehicle: (j) Includes the following additional provisions: 5. Petitioner further requests that the Court issue an ex parte (emergency) protection order under R.C. 3113.31(D) and (E) and this Petition. 6. Petitioner further requests that the Court issue no mutual protection orders or other orders against Petitioner unless all of the conditions of R.C. 3113.31(E)(4) are met. FORM 10.01-D: PETITION FOR DOMESTIC VIOLENCE CIVIL PROTECTION ORDER Amended: July 1, 2010 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Page 3 of Form 10.01-D] 7. Petitioner further requests that if Petitioner has a victim advocate, the Court permit the victim advocate to accompany Petitioner at all stages of these proceedings as required by R.C. 3113.31(M). 8. Petitioner further requests that the Court grant such other relief as the Court considers equitable and fair. 9. Petitioner lists here all present court cases and pertinent past court cases (including civil, criminal, divorce, juvenile, custody, visitation, and bankruptcy cases) that relate to the Respondent, you, your children, your family, or your household members: CASE NAME CASE NUMBER COURT/COUNTY TYPE OF CASE RESULT OF I hereby swear or affirm that the answers above are true, complete, and accurate to the best of my knowledge. I understand that falsification of this document may result in a contempt of court finding against me which could result in a jail sentence and fine, and that falsification of this document may also subject me to criminal penalties for perjury under R.C. 2921.11. Sworn to and subscribed before me on this of , d . SIGNATURE OF PETITIONER DO NOT WRITE YOUR ADDRESS BELOW IF YOU ARE REQUESTING CONFIDENTIALITY. PLEASE PROVIDE AN ADDRESS WHERE YOU CAN RECEIVE NOTICES FROM THE COURT. NOTARY PUBLIC Signature of Attorney for Petitioner (if applicable) Name Address Attorney Registration Number Phone Number FORM 10.01-D: PETITION FOR DOMESTIC VIOLENCE CIVIL PROTECTION ORDER Amended: July 1, 2010 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Page 4 of Form 10.01-D] The following local service agencies provide legal assistance and/or support services for victims of domestic violence: Legal Aid 241-9400 Butler County Mental Health 896-7887 Community Counseling and Crisis Center 523-4146 Middletown Health Center 424-2466 Ohio Victims of Crime Compensation Program 1-800-824-8263 Prosecuting Attorney 887-3437 Resolutions Domestic Violence Program 867-2804 or 867-2653 Domestic Relations (Civil Protection Orders) 887-3347 Family Service of Butler County 868-3245 or 867-7574 Children’s Diagnostic Center 868-1562 Dove House Protective Shelter 863-7099 Butler County Victim/Witness Division 887-3447 or 887-3796 Probation Adult: 878-3398 Juvenile: 887-3318 Parachute (Child Advocacy) (513) 867-5010 FORM 10.01-D: PETITION FOR DOMESTIC VIOLENCE CIVIL PROTECTION ORDER Amended: July 1, 2010 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com