STATE OF SOUTH DAKOTA COUNTY OF ) ) ) IN CIRCUIT COURT JUDICIAL CIRCUIT Petitioner TPO NO._____________________ -vs- PETITION AND AFFIDAVIT FOR A PROTECTION ORDER (DOMESTIC ABUSE) Respondent I, , the above-named Petitioner, or the Parent/Guardian of the minor child Petitioner, being duly sworn upon oath, state and affirm the following: I am a resident of County, South Dakota. The Respondent is a resident of County, South Dakota. The person I am asking the Court to restrain from committing acts of domestic abuse is (check all that apply): a spouse (married); a former spouse (divorced); a person related to me by blood or adoption (specify relationship___________________________); a person who lives with me in the same household (lease or own by petitioner, respondent or both) __________________________________________________________________________________; a person with whom I have lived with in the past; a person with whom I have had a child. I AM ASKING THE COURT FOR A PROTECTION ORDER BASED UPON THE FACTS BELOW: (day) , (year) , at approximately o’clock (am/pm), On or about (month) the person against whom I seek this Protection Order committed the following act(s) of domestic abuse: The person caused me physical harm or bodily injury. The person attempted to cause me physical harm or bodily injury. The person’s actions have made me fearful that he/she is about to cause me physical harm or bodily injury. The person violated a protection order. The person willfully, maliciously, and repeatedly followed me. The person harassed me by pursuing a knowing and willful course of conduct which seriously alarms, annoys, or harasses me, with no legitimate purpose. The pattern of conduct is a series of acts over a period of time, however short, showing a continuing pattern of harassment. The person made a credible threat with the intent to place me in a reasonable fear of death or great bodily injury. The person willfully, maliciously, and repeatedly harassed me by means of any verbal, electronic, digital media, mechanical, telegraphic, or written communication. I, as the Petitioner, have been the victim of a crime of violence. 1 Form UJS-091A (Domestic Petition) Rev. 05/08 American LegalNet, Inc. www.FormsWorkflow.com Provide a detailed description of what happened on the above date: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Yes Yes No No Don’t Know Don’t Know Yes Yes No No Don’t Know Don’t Know Yes No Don’t Know Yes Yes Yes No No No Don’t Know Don’t Know Don’t Know Was law enforcement called? Was the person against whom you seek protection arrested for this incident? Is the person in jail? Has the person violated previous protection orders? If so, against whom________________________________________ Give the date of the violation_______________ and the county and state of the violation Has the person been found guilty of violating previous protection orders? If so, against whom Give the date of the conviction _______________ and the county and state of the conviction Does the person possess guns or weapons? Was a weapon used in this incident? Has the person threatened anyone with a weapon? Provide a detailed description of other similar incidents or actions that the person has committed and reasons you believe it will continue: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 2 Form UJS-091A (Domestic Petition) Rev. 05/08 American LegalNet, Inc. www.FormsWorkflow.com Continued from Page 2 _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ REQUEST FOR HEARING AND PROTECTION ORDER Based upon this Petition and Affidavit in which I truthfully set forth the details of the domestic abuse, I respectfully ask the Court to set a date to hear this matter and after hearing the evidence, to grant me a Protection Order: 1) To Restrain the Respondent from acts of abuse and physical harm, making threats of abuse, stalking or harassment. 2) To Grant the Protection Order for a period of time (no longer than 5 years). 3) To exclude the Respondent from the Petitioner’s residence listed in 4C. 4) To Order that the Respondent shall not come within a distance of ___________ from the following persons and places: A. The Petitioner personally B. The following minor children named as other protected persons: Name Date of birth Relationship ___________________________ ___________ _______________________________ ___________________________ ___________ _______________________________ ___________________________ ___________ _______________________________ C. The Petitioner’s residence (street/apt)___________________________________________ (city)__________________________________, (state) _______. (zip) ________ - ____ D. The Petitioners place employment (street)________________________________________ (city)_______________________________, (state)_______ (zip) _________-________ E. Other places (street/apt) (city) , (state)_______ (zip) (street/apt) (city) , (state)_______ (zip) (street/apt) (city) , (state)_______ (zip) 5) To award me temporary custody of our minor child(ren), whose names are ___________________ _______________________________________________________________________________ 6) To establish temporary visitation for the respondent with the minor child(ren) named above consisting of: Existing order in File #____________________ Supervised at _____________________ Jurisdiction: South Dakota South Dakota tribe Other State ____________ Other Other Visitation: ____________________________________________________________ ______________________________________________________________________________ 3 Form UJS-091A (Domestic Petition) Rev. 05/08 American LegalNet, Inc. www.FormsWorkflow.com 7) To Order that the Respondent shall pay temporary (If you are requesting support, you must provide proof of the monthly income of both parties at the hearing.): child support in the amount of $ a month starting on and continuing until further order of the Court; Child support shall be paid to: Office of Child Support Enforcement Kneip Building 700 Governors Drive Pierre, SD 57501 spousal support in the amount of $ a month starting on and continuing until further order of the Court. Spousal support shall be paid to the Clerk of Courts Office in the county this order was filed. 8) To Order the parties receive parenting classes approved or provided by the Department of Social Services, SDCL 25-10-5. 9) To Order the parties to obtain counseling as follows: 10) That the Respondent be restrained from contact with the Petitioner or other protected persons, by any direct or indirect means except as authorized by a court order. 11) To Order other relief which I believe is necessary for my protection or for the protection of a household member as follows: (If you are requesting an immediate temporary protection order without notice to the person you want restrained and without an opportunity for the person to appear, you must state why you believe you will suffer immediate and irreparable injury or damage if you have to wait until the hearing.) REQUEST FOR IMMEDIATE PROTECTION ORDER WITHOUT NOTICE TO THE OTHER PARTY I am not requesting an immediate Temporary Protection Order. In addition to what I have requested in sections 1-10 above, I further request that the Court grant me an immediate Temporary Protection Order restraining the Respondent from committing acts of domestic abuse based upon the following sworn statements and beliefs: The reasons I need this order immediately and cannot wait until the scheduled hearing are: I believe that I will suffer immediate and irreparable injury, loss or damage if I am not granted an immediate Temporary Protection Order without notifying the Respondent and his/her attorney or giving the other party an opportunity to be heard. 4 Form UJS-091A (Domestic Petition) Rev. 05/08 American LegalNet, Inc. www.FormsWorkflow.com The immediate and irreparable injury, loss or damage that I believe I will suffer is: On this _____ day of _____________, ________, I swear or affirm under oath that the information I have provided in this Petition and Affidavit are true and correct to the best of my knowledge. I believe I am entitled to the protection I have requested. I am asking for this protection for valid reasons and am not attempting to harass the person I am seeking protection against and am not attempting to abuse or delay the court process or any other legal action. Petitioner Signed and sworn to before me on this day of , . Notary Public/Deputy Clerk of Courts Commission Expires: (SEAL) 5 Form UJS-091A (Domestic Petition) Rev. 05/08 American LegalNet, Inc. www.FormsWorkflow.com