Case No. Petition for Orders of Protection Court County Tennessee PETITIONER/PLAINTIFF First Middle Last PETITIONER/PLAINTIFF IDENTIFIERS Date of Birth of Petitioner V. RESPONDENT RESPONDENT IDENTIFIERS SEX First EYES Middle RACE HAIR DOB HT WT Last Relationship to Petitioner SOCIAL SECURITY # Respondent’s Address Distinguishing Features Respondent’s Employer No one shall be denied an Order of Protection for failure to provide any or all of the respondent’s identifying information. CAUTION: oWeapon Involved Petitioner, , pursuant to Tennessee Code Annotated, Section 36-3-601 et seq., states: 1. Petitioner and respondent are: (A) Adults or minors who are current or former spouses; (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 were formerly related by marriage; or (F) Adult or minor children of a person in a relationship that is described in subdivisions (A)- (E). 2. The Parties have minor child(ren). (Write name and age of each child below.) Page 1 of 4 American LegalNet, Inc. www.USCourtForms.com 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:) Petitioner 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. Respondent has abused and/or threatened to abuse petitioner. Specifically, respondent has: (Write what happened, when it happened, and where it happened on the following lines; attach additional pages if necessary.) 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 11, check ONLY the paragraphs that apply.) 9. Petitioner needs support for the parties’ minor child(ren). 10. Petitioner needs support for the petitioner. 11. Respondent refuses to leave the parties’ residence. (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. Petitioner or Respondent has filed for a divorce. 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 or threatening to commit domestic abuse against the petitioner or the petitioners’ 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 prohibiting the respondent from stalking the petitioner, as defined in T.CA. § 39-17-315; 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 pursuant to Tennessee Code Annotated Section 36-3-605, and that notice of said hearing be served upon respondent with the 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 8, 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 petitioner, 6. That upon the hearing of this cause, respondent be ordered to pay reasonable support for 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 petitioner, 8. That respondent be directed to attend available counseling programs that address violence and control issues or substance abuse problems. 9. That respondent pay the costs and litigation tax of this cause; 10. For general relief. THIS IS THE FIRST APPLICATION FOR EXTRAORDINARY PROCESS IN THIS CAUSE. Page 3 of 4 American LegalNet, Inc. www.USCourtForms.com 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 Protection should not issue. Judge and show cause why an Order of Date OFFICER’S RETURN Served on respondent by [check one] personally reading the Order to respondent and by leaving a copy of the Order with respondent, 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. Clerk/Deputy Clerk or Authorized Officer Page 4 of 4 American LegalNet, Inc. www.USCourtForms.com