Petition for Order of Protection and Order for Hearing In the Case # (the clerk fills this in): Court of County, TN Petitioner’s name (person needing protection) [**Petitioner’s children under 18 that are in need of protection are listed below]: If Petitioner is under 18, insert child’s name if filed on behalf of an unemancipated person (someone under 18 years of age) pursuant to TCA §36-3602. This request is being made by ____________________________ who is child’s parent or legal guardian or a caseworker. __________________________________ _____ first middle last **PETITIONER’S CHILDREN UNDER 18 THAT PETITIONER BELIEVES ARE IN NEED OF PROTECTION: Name Age Relationship to Respondent Name 1. Relationship to Respondent 3. 2. Age 4. Respondent’s Information (person you want to be protected from): first middle _ date of birth (MM/DD/YYYY) last street address city state zip Respondent’s Employer: Employer’s name Employer’s phone # Describe Respondent: Sex Race Hair Eyes Height – Weight – SSN – Other Male White Black Brown Height Female Asian Grey Hazel Weight Black Blond Blue Hispanic Bald Green Other: Brown Gray Other: ________ Other: 1 Social Sec. # (Provided to Clerk’s office if known) Scars/Special Features Phone Number What is your relationship to the Respondent? (Check all that apply): a. b. c. d. e. f. g. h. i. 2 Warning! We are married or used to be married. Weapon involved We live together or used to live together. Has or owns a weapon We have a child together. We are dating, used to date, or have had sex. We are relatives, related by adoption, or are/were in-laws. (Specify): We are the children of a person whose relationship is described above (Specify): The Respondent has stalked me. The Respondent has sexually assaulted me. Other: List all children under 18 that you have: * Check here if listing addresses would put you or your child in danger. If so, leave any spaces for addresses blank. Name of Child Age Is Respondent the Does the child need Child’s address parent of the child? to be protected from (Write “yes” or “no”) the Respondent? 12/13/10 Petition for Order of Protection page 1 American LegalNet, Inc. www.FormsWorkFlow.com 3 Where else have the children (that you and Respondent have together) lived during the last 6 months? Children’s previous addresses 4 Who did they live with at this address? Other Court Cases – Are the children that you and Respondent have together involved in any other court case in Tennessee or another state? Yes No If “Yes,” fill out below: Case Number (if you know it): County and State of other case: Kind of case (check all that apply): 5 Domestic Violence Criminal Juvenile Child Support Other (specify): Custody Rights – Does anyone besides you or the Respondent claim to have custody or visitation rights to the children that you and Respondent have together? Yes No If “Yes,” who? Name 6 Divorce Address Describe Abuse – (use additional sheets of paper if necessary and attach to Petition) Describe abuse, stalking or assault (include, IF APPLICABLE, information about abuse or fear of abuse to your child(ren), personal property or animals) 12/13/10 Petition for Order of Protection Where and when did this happen? Describe any weapons used. page 2 American LegalNet, Inc. www.FormsWorkFlow.com I ask the court to make the following Orders after the hearing: (check all that apply) 7 No Contact Please order the Respondent to not contact: me our children under 18, either directly or indirectly, by phone, email, messages, text messages, mail or any other type of communication or contact. 8 Stay Away Please order the Respondent to stay away from me for any purpose. 9 my home my workplace or from coming about Personal Conduct Please order the Respondent not to: Cause intentional damage to my property or interfere with the utilities at my home. Hurt or threaten to hurt any animals that I/we own or keep. Temporary Custody Please give me temporary custody of our children. Child Support Please order the Respondent to pay reasonable child support. Petitioner Support (if married) Please order the Respondent to pay reasonable spousal support. Move-out / Provide other housing Please order the Respondent to (check one): move out of our family home immediately or provide other suitable housing (if married) Check here if your home or lease is in the Respondent’s name only. If the parties share a residence, please allow the Respondent to obtain his/her clothing and personal effects such as medicine and other things he/she may need. Counseling/Substance Abuse Programs Please order the Respondent to go to a certified batterers’ intervention program if one available in the area or a counseling program. No Firearms Please order the Respondent not to have, possess, transport, buy, receive, use or in any other way get any firearm. List all firearms that the Respondent owns, controls, or has access to: 12/13/10 Petition for Order of Protection page 3 American LegalNet, Inc. www.FormsWorkFlow.com Animals / Pets Please give me custody and control of any animal owned, possessed, leased, kept or held by me, the Respondent, or the children listed above. Costs, fees, and litigation taxes Please order the Respondent to pay all court costs, lawyer fees, and taxes for this case. Other Orders: (General Relief) I also ask the court to: 1. Make an immediate Temporary Order of Protection. (Ex-Parte Order of Protection) 2. Notify law enforcement in this county of that Order. 3. Serve the Respondent a copy of that Order and Notice of Hearing to take place within 15 days of service. 4. Serve a copy of the Request, Notice of Hearing and Temporary Order on the parents of the Petitioner (if the Petitioner is under 18 years of age) unless the Court finds that this would create a serious threat of serious harm to the Petitioner. T.C.A. §36-3-605 (c ) Petitioner (or parent/legal guardian/caseworker) signs here in front of notary/clerk/judicial officer and swears that he/she believes the above information is true: Date: Notary fills out below – I declare that the Petitioner has read this Petition, and swears it be true to the best of her/his knowledge. Sworn and subscribed before me, the undersigned authority, By (Print name of notary): On this date: Notary or Court Clerk or Judicial Officer signs here Date notary’s commission expires The court finds good cause and will issue a Temporary Order of Protection. ********************************************************************************************** The court does not find good cause and denies a Temporary Order of Protection - The court finds there is no immediate and present danger of abuse to the petitioner and denies the Petitioner’s request for a Temporary Order of Protection. The court will set the matter for hearing. ORDER FOR HEARING The Petitioner and Respondent must go to court and explain to the judge why the judge should or should not issue an Order of Protection against the Respondent. This hearing will take place on (date): ________________ at (time): _______ a.m. p.m. at (location): Date Judicial Officer’s signature 12/13/10 Petition for Order of Protection page 4 American LegalNet, Inc. www.FormsWorkFlow.com Proof of Service of Petition, Notice of Hearing and Temporary Order of Protection: If the Petitioner is under 18 (and Petitioner is a social worker filing on behalf of a minor) and service of these Respondent was served on (date): at (time): by (check one): Personal service U.S. Mail per TCA §§ 20-2-215 and 20-2-216 (The Respondent does not live in Tennessee.) documents would not put him/her at risk, the Clerk will serve and fill out below. (TCA § 36-3-605(c)) Server’s signature ____________________________________________ Print Name Petitioner was served on (date): at (time): Personal service I served the child’s parents of copies of the Petition, Notice of Hearing, and Temporary Order of Protection by personal delivery at (address): or U.S. Mail on: (date): Clerk’s signature: by (check one): ____________________________________________ Server’s signature ____________________________________________ Print Name Notice to the Respondent about Firearms If the court grants the Petitioner’s request for a Protective Order: You will not be able to have a firearm while this or any later protective order is in effect. You will have to transfer all firearms in your possession within 48 hours to any person who is legally allowed to have them. 18 U.S.C. §922(g)(8), TCA §36-3-606(g), TCA §36-3-625. You will not be allowed to buy a firearm until the court says otherwise. 12/13/10 Petition for Order of Protection page 5 American LegalNet, Inc. www.FormsWorkFlow.com