SUP. CT. FORM 10.01-D DV-4 (May 1, 2007) [Discard all previous versions of this form] IN THE COMMON PLEAS COURT OF MONTGOMERY COUNTY, OHIO DIVISION OF DOMESTIC RELATIONS Petitioner : Case No. Address : Judge City, State, Zip Code : Date Of Birth: : : v. PETITION FOR DOMESTIC VIOLENCE CIVIL PROTECTION ORDER (R.C. 3113.31) : Respondent : Notice to Petitioner: Throughout this form, that applies. check every Address : City, State, Zip Code Date Of Birth: Do NOT write your address at left or below if you are requesting confidentiality. : 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 Person “living as a spouse of Respondent” defined as: • now cohabiting; or • cohabited within five years prior to the alleged act of domestic violence 2. Petitioner seeks relief on behalf of the following family or household members: NAME AGE/DOB HOW RELATED TO PETITIONER RESPONDENT 1 RESIDES WITH American LegalNet, Inc. www.FormsWorkflow.com 3. Respondent has engaged in the following act(s) of domestic violence (describe the acts as fully as possible, add additional pages if necessary): 4. Petitioner requests that the Court grant relief under Ohio Revised Code 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 Ohio Revised Code 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 Ohio Revised Code 3113.31 (E)(4) are met. 2 American LegalNet, Inc. www.FormsWorkflow.com 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 Ohio Revised Code 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 you, your children, your family, or household members: CASE NAME CASE NUMBER COURT/COUNTY TYPE OF CASE RESULT OF CASE 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 Ohio Revised Code 2921.11. Sworn to and subscribed before me on this of , day . SIGNATURE OF PETITIONER Address where Petitioner can be contacted: NOTARY PUBLIC Signature of Attorney for Petitioner (if applicable) Name Address Attorney Registration Number 3 American LegalNet, Inc. www.FormsWorkflow.com