Petition for Orders of Protection Case No. Court _____________________________ County Tennessee PETITIONER/PLAINTIFF First Middle Last PETITIONER/PLAINTIFF IDENTIFIERS Date of Birth of Petitioner Minor Children Protected Under this Order: ________________________________________________ ________________________________________________ V. RESPONDENT RESPONDENT IDENTIFIERS SEX First Middle RACE DOB HT WT HAIR SOCIAL SECURITY # Last EYES Relationship to Petitioner _________________________________ Respondent’s Address ______________________________________ ________________________________________________________ Respondent’s Employer __________________________________ Distinguishing Features _____________________________ ________________________ CAUTION: Weapon Involved Respondent owns/possesses a firearm Relationship Identifiers (Mark all that apply): Parents of Child in Common Child of Respondent Live Together or Have Lived Together Current or Former Spouses Child of Respondent's Intimate Partner Other (Explain): _____________________________ Petitioner, __________________________, pursuant to Tennessee Code Annotated, Section 36-3-601 et seq., states: 1. Petitioner and respondent are: Adults or minors who are current or former spouses; (A) (B) Adults or minors who live together or who have lived together; (C) Adults or minors who are dating or who have dated or who have or had a sexual relationship, [as used herein “dating” and “dated” do not include fraternization between two (2) individuals in a business or social context]; (D) Adults or minors related by blood or adoption; (E) Adults or minors who are related or where formerly related by marriage; or (F) Adult or minor children of a person in a relationship that is described in subdivisions (A)-(E); or (G) Respondent has stalked Petitioner; or (H) Respondent has sexually assaulted the Petitioner Revised 7-1-05 Page 1 of 4 American LegalNet, Inc. www.USCourtForms.com 2. The Parties have _______ minor child(ren). (Write name and age of each child below.) ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 3. (Check ONE of the following if custody of minor child(ren) is involved:) _______ The health, safety, or liberty of the petitioner and/or the parties’ minor child(ren) would be jeopardized by disclosure of identifying information. OR _______ The child(ren)’s present address is _____________________________________________. The child(ren) has/have lived at the following address(es) for the past five years: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ AND _______ The names and addresses of the persons with whom the parties’ minor child(ren) has/have lived during the last five years are: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 4. (Check ONE of the following if custody of minor child(ren) is involved:) _______ Petitioner is not aware of any prior pending actions concerning the custody of the parties’ minor child(ren) in this or any other State. OR _______ Petitioner is aware of the following prior or pending actions concerning the custody of the parties’ minor child(ren) in this or any other State: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 5. (Check ONE of the following if custody of minor child(ren) is involved:) _______ Peitioner does not know of any person not a party to this proceeding who has physical custody of the parties’ minor child(ren) or claims rights of custody or visitation with the parties’ minor child(ren). OR _______ Petitioner knows of the following person(s) who have physical custody of the parties’ minor child(ren) or claim rights of custody or visitation with the parties’ minor child(ren): ________________________________________________________________________________________________ ________________________________________________________________________________________________ 6. Petitioner has been subject to threatened with or placed in fear of domestic abuse, stalking or sexual assault by respondent. Specifically, respondent has: (Write what happened, when it happened, and where it happened on the following lines; attach additional pages if necessary.) ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Revised 7-1-05 Page 2 of 4 American LegalNet, Inc. www.USCourtForms.com 7. Petitioner is in an immediate and present danger of abuse by respondent. 8. Petitioner’s minor child(ren) is/are in immediate and present danger of abuse by respondent. (For Paragraphs 9 through 14, check ONLY the paragraphs that apply.) _______ 9. Petitioner need support for the parties’ minor child(ren). _______ 10. Petitioner needs support for the petitioner. _______ 11. Respondent refuses to leave the parties’ resident. (If you check paragraph 11, please check one of the following.) _______ Respondent is the sole _____________________ (Owner or Lessee) of the parties’ residence. _______ Respondent is not the sole owner or lessee of the parties’ residence. _______ 12. Respondent owns or possesses firearms. _______ 13. Respondent has used or threatened to use firearms against petitioner and/or petitioner's minor child(ren). _______ 14. Respondent is in military service. WHEREFORE, PETITIONER PRAYS: 1. That an ex parte Order of Protection, as provided for in Tennessee Code Annotated Section 36-3-605, be immediately issued directing the respondent to refrain from committing domestic abuse, stalking or sexual assault; or threatening to commit domestic abuse, stalking or sexual assault against the petitioner or the petitioner’s minor child(ren); prohibiting the respondent from telephoning, contacting, or otherwise communicating with the petitioner, directly or indirectly or coming about petitioner for any purpose; and that copies of said order be served upon the respondent and filed with the local law enforcement agency; 2. That a hearing in this cause be set within fifteen days after service of this petition to the respondent, pursuant to Tennessee Code Annotated Section 36-3-605, and that notice of said hearing be served upon respondent with any ex parte Order of Protection; 3. That upon a hearing of this cause, petitioner be granted an extended Order of Protection for one year; (For Paragraphs 4 through 9, check only the paragraphs that apply.) _______ 4. That upon the hearing of this cause, petitioner be awarded temporary custody of the parties’ minor child(ren). _______ 5. That upon the hearing of this cause, respondent be ordered to pay reasonable support for the petitioner. _______ 6. That upon the hearing of this cause, respondent be order to pay reasonable support for the parties’ child(ren); _______ 7. That upon the hearing of this cause, exclusive possession of the parties’ residence be awarded to petitioner or that respondent be ordered to provide alternative housing for the petitioner; _______ 8. That respondent be directed to attend available counseling programs that address violence and control issues or substance abuse problems; _______ 9. That respondent be prohibited from owning, possessing, transporting or using a firearm or ammunition. 10. That respondent pay the costs, attorney fees and litigation tax of this cause; Revised 7-1-05 Page 3 of 4 American LegalNet, Inc. www.USCourtForms.com _______ 11. For any other relief that might be necessary to protect the safety of the petitioner and parties' or Petitioner’s minor child(ren)________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 12. For general relief. THIS IS THE FIRST APPLICATION FOR EXTRAORDINARY PROCESS IN THIS CAUSE. STATE OF TENNESSEE COUNTY OF ___________________ _______________________________________, being first duly sworn, makes an oath that the petitioner has read the foregoing petition, knows the contents thereof and that the contents thereof are true and correct to the best of the petitioner’s knowledge, information, and belief. ______________________________________ PETITIONER Sworn to and subscribed before me this _____________________________, 20______. By:___________________________________ Notary/Court Clerk My commission expires:_______________________ FIAT [For use when no Ex Parte Order is issued.] To the Clerk: Issue a show cause order for the respondent to appear on ___________________ and show cause why an Order of Protection should not issue. __________________________________________ Judge ____________________________ Date Return of Service Served on respondent [check one] ______ by personal service on a resident of Tennessee OR ______ by mail on a non-resident of Tennessee in the manner as set forth in Tennessee Code Annotated §§ 20-2-215 and 20-2-216, on ___________________________, 20____ at ________ a.m./p.m. ___________________________________________ [Signature of person serving Order on Respondent] Revised 7-1-05 Page 4 of 4 American LegalNet, Inc. www.USCourtForms.com