Sexual Assault Petition Page 1 of 5 September 1, 2015 Circuit Court of the Judicial District, County of , State of Wyoming Name: Petitioner, vs. SA Name: Respondent. PETITION FOR SEXUAL ASSAULT PROTECTION ORDER UNDER W.S. 7-3-506 THROUGH 7-3-511 Please see Sexual Assault Protection Order packet instructions for details regarding acts which constitute sexual assault or sexual abuse of a minor that qualify the Petitioner to seek a Sexual Assault Protection Order. 223Sexual Assault224 means any act made criminal pursuant to W.S. 2476-2-302 and 2476-2-303 and 2476-2-314 through 2476-2-318 or an attempt or conspiracy to commit such act. 1. Petitioner is or is filing on behalf of: An adult victim of nonconsensual sexual intrusion committed by the Respondent (W.S. 2476-2-302 or 2476-2-303); or A minor victim of nonconsensual sexual intrusion or contact by the Respondent (W.S. 2476-2-314, 2476-2-315, 2476-2-316 (i-iii), 2476-2-317); A minor victim who is subjected to immodest, immoral or indecent liberties by the Respondent (W.S. 2476-2-316 iv); A person less than fourteen (14) years of age or a person purported to be less than the age of fourteen (14) years and was solicited by the Respondent to engage in illicit sexual intrusion (W.S. 2476-2-318); or A person subject to an attempt or conspiracy by the Respondent to commit any of the above referenced acts. 2. I am filing; On behalf of myself and I am 18 years or older. American LegalNet, Inc. www.FormsWorkFlow.com Sexual Assault Petition Page 2 of 5 September 1, 2015 On behalf of a minor who is years old. My relationship to the minor is . My name is . On behalf of a vulnerable adult defined in W.S. 35-20-102(a)(xviii) or any other adult who because of age, disability, health or inaccessibility, cannot file the petition. My relationship with this adult is . My name is . With the consent of the victim and I am a District Attorney or County Attorney. 3. This Court has jurisdiction because: Petitioner resides in the county. Respondent may be found in the county. 4. Respondent222s age is . If the Respondent is under the age of 18, the name of the Respondent222s parent or legal guardian is . 5. Petitioner222s relationship to Respondent is: . 6. If the Petitioner and the Respondent are involved together in a criminal case with the same or similar allegations as set forth herein please identify the court and case number: 7. An order of protection is being requested because the Respondent did the following acts (describe the acts or series of acts, using specific dates, if possible): (Attach additional pages if needed.) American LegalNet, Inc. www.FormsWorkFlow.com Sexual Assault Petition Page 3 of 5 September 1, 2015 I request this Court order (please check appropriate paragraphs below): 8. I believe that a clear and present danger of further sexual assault or of serious physical adverse consequences exists. Therefore I request an ex parte temporary order of protection be entered. 9. I request the Court order the following relief: Restrain Respondent from any further acts of sexual assault or from contacting, harassing, or threatening the victim of the alleged offense and any other person including but not limited to members of the victims family or household as named below. Contact either directly or indirectly, including, but not limited to, communication verbally in person, communication by telephone or other electronic means, written communication in any form, communication through third persons, and nonverbal communication and gestures. Prohibited contact under this paragraph includes telephone calls, mail, e-mail, texting, fax, contacting through social media using the internet or similar technology and any other form of communication. Order Respondent not to contact the following people (state their relationship to the victim and the reason why these individuals need protection): Order Respondent to stay away from the following locations: Home Check here if the Petitioner is requesting the Court to order the address of the Petitioner be kept confidential. School Business Place of employment Daycare Other location (describe) American LegalNet, Inc. www.FormsWorkFlow.com Sexual Assault Petition Page 4 of 5 September 1, 2015 Restrain Respondent from attending classes attended by the petitioner at (school) ; If this relief is requested it is done so for the following reasons: Require the Respondent to surrender any firearm or other dangerous weapons and prohibit the Respondent from obtaining or possessing a firearm. 10. I request the following additional relief: 11. Respondent's personal information (put as much information as you know): Other names used by Respondent Home Address Mailing Address (if different) Employment Address Date of Birth Gender Race Age Height Weight Glasses Hair Color Eye Color Facial Hair Scars, Tattoos, Other Markings Respondent's Vehicle Make Year Model Color State Licensed License Number Firearms owned or ammunition in possession of Respondent INTENTIONALLY LEFT BLANK American LegalNet, Inc. www.FormsWorkFlow.com Sexual Assault Petition Page 5 of 5 September 1, 2015 Dated this day of, 20. Petitioner State of Wyoming County of Subscribed and sworn to before me this day of , 20 , by . Notary Public/Court Clerk My commission expires: American LegalNet, Inc. www.FormsWorkFlow.com