STATE OF SOUTH DAKOTA COUNTY OF ) ) ) , IN CIRCUIT COURT ________________ JUDICIAL CIRCUIT Petitioner, -vs, Respondent. TPO NO._____________________ PETITION AND AFFIDAVIT FOR A PROTECTION ORDER (STALKING, OR PHYSICAL INJURY AS A RESULT OF AN ASSAULT, OR A CRIME OF VIOLENCE) I, __________________________________ the above named Petitioner, or the Parent/Legal Guardian of the minor child Petitioner (the Filer), being duly sworn upon oath, state and affirm the following: At least one party to the protection order--Petitioner, Respondent (the person against whom I seek this Protection Order), or a Protected Party (a minor child in my custody also victimized by Respondent)--is a South Dakota resident. Petitioner resides in _____________________ County, _____________________ (state); Respondent resides in _____________________ County, _____________________ (state); and any Protected Parties not residing with Petitioner or Respondent, reside in _________________________ County, ______________________ (state). I AM ASKING THE COURT FOR A PROTECTION ORDER BASED UPON THE FACTS BELOW: On or about (month) (day) (year) at approximately o'clock (am/pm), Respondent committed the following act(s) that seriously alarmed, annoyed, or harassed Petitioner (if not me, my minor child), and any Protected Parties (check all that apply): Respondent willfully, maliciously, and repeatedly followed Petitioner and/or any Protected Parties. Respondent pursued a knowing and willful course of conduct which seriously alarmed, annoyed or harassed with no legitimate purpose. The pattern of conduct was a series of acts over a period of time, however short, showing a continuing pattern of harassment. Respondent made a credible threat with intent to cause reasonable fear of death or great bodily injury. Respondent willfully, maliciously, and repeatedly harassed Petitioner and/or any Protected Parties by means of any verbal, electronic, digital media, mechanical, telegraphic, or written communication. Respondent caused physical injury as a result of an assault. Respondent committed a crime of violence. Provide a detailed description of what happened on the above date: 1 Form UJS-121A (Stalking Petition) Rev. 05/16 American LegalNet, Inc. www.FormsWorkFlow.com Yes Yes Yes Yes No No No No Don't Know Don't Know 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 for this incident? Was Respondent arrested for this incident? Is Respondent in jail? Has Respondent violated previous protection orders? If so, against whom_______________________________________ Give the date of the violation________________ and the county and state of the violation______________________________________ Has Respondent 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 Respondent possess guns or weapons? Was a weapon used in this incident? Has Respondent threatened anyone with a weapon? Provide a detailed description of other similar incidents or actions (please include dates and times, if possible): 2 Form UJS-121A (Stalking Petition) Rev. 05/16 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 stalking, physical injury, and/or crime of violence, I respectfully ask the court to set a date to hear this matter and after hearing the evidence, to grant Petitioner and any Protected Parties a Protection Order: 1) To Restrain Respondent from: a) following or harassing, or making any credible threat with the intent to place Petitioner and any Protected Parties in reasonable fear of death or great bodily injury, SDCL 22-19A-1; b) causing any injury as a result of an assault or a crime of violence, SDCL 22-1-2(9). 2) To grant the Protection Order for a period of time (no longer than 5 years). 3) To exclude Respondent from Petitioner's residence listed in 4C. 4) To Order that 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 Parties: Additional names attached Name Date of birth Relationship ___________________________ ___________ _______________________________ ___________________________ ___________ _______________________________ ___________________________ ___________ _______________________________ ___________________________ ___________ _______________________________ C. Petitioner's residence (street/apt)_________________________________________________ (city)__________________________________, (state) _______. (zip) ________ - _____ D. Petitioner's 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) That Respondent be restrained from contact with Petitioner and any Protected Parties, by any direct or indirect means except as authorized by a court order. 6) To Order other relief which I believe is necessary for Petitioner's protection and any Protected Parties' protection, as follows: 3 Form UJS-121A (Stalking Petition) Rev. 05/16 American LegalNet, Inc. www.FormsWorkFlow.com (If you are requesting an immediate temporary protection order without notice to Respondent and without an opportunity for Respondent to appear; you must state why you believe Petitioner or any Protected Parties will suffer immediate and irreparable injury or damage if you or they have to wait until