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CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR Located (Maryland Judiciary)

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vs.
Petitioner
Respondent
Address
☐ CIRCUIT COURT ☐ DISTRICT COURT OF MARYLAND FOR
Located at Case No.
(NOTE: Fill in the following, checking the appropriate boxes. Petitioners need not give an address if doing so risks
further abuse or reveals the confidential address of a shelter. If this is the case, check here
☐ If you need additional
paper, ask the clerk.)
PETITION FOR PROTECTION FROM
☐ DOMESTIC VIOLENCE ☐ CHILD ABUSE ☐ VULNERABLE ADULT ABUSE
(Family Law § 4-504)
1. I am ☐ the current or former spouse of the respondent; ☐ a cohabitant of the respondent; ☐ a person related to the
r
espondent by blood, marriage, or adoption; ☐ a parent, stepparent, child, or stepchild of the respondent or the pers
on
e
ligible for relief who resides or resided with the respondent or person eligible for relief for at least 90 days within
(one) 1 year before the filing of the petition; ☐ a vulnerable adult; ☐ an individual who has a child in common with
the respondent; ☐ an individual who has had a sexual relationship with the respondent within one (1) year before the
filing of the petition; or ☐ an individual who alleges that within six (6) months before the filing of the petition the
respondent committed rape or a sexual offense or attempted rape or sexual offense against the individual.
2. I want relief for ☐ myself ☐ minor child ☐ vulnerable adult, from abuse by .
The respondent, whose present whereabouts (if known) are ,
committed the following acts of abuse against
on or about, (check all that apply) ☐ kicking ☐ punching ☐ choking/strangling
☐ slapping ☐ shooting ☐ rape or other sexual offense (or attempt) ☐ hitting with object ☐ stabbing ☐ shoving
☐ threats of violence ☐ mental injury of a child ☐ detaining against will ☐ stalking ☐ biting ☐ revenge porn
☐ other
The details of what happened are:
3. (If the victim is a child or vulnerable adult, fill in the following): I am asking for protection for a ☐ child
☐ vulnerable adult whose name is .
At this time the victim can be found at .
I am ☐ State’s Attorney ☐ DSS ☐ a relative ☐ an adult living in the home.
4. The person(s) I want protected are (include yourself if you are a victim):
Name(s) Birthdate Relationship to Respondent
City/County
Court Address
(Give specific details of what happened, when and where it happened, and any injuries sustained)
Name of alleged abuser
Date
CC-DC-DV-001 (Rev. 06/2021) Page 1 of 3
Address
City, State, Zip
City, State, Zip
Home Telephone No. Work Telephone No.
Home Telephone No. Work Telephone No.
Case No.
5. The person(s) I want protected now lives, or has lived, with the respondent for the following period of time during
the past year:
There ☐ are ☐ are not additional persons living in the home.
6. I know of the following court cases involving me, or the person I want protected, and the respondent. (examples
include: paternity, child support, divorce, custody, domestic violence, juvenile cases, criminal cases).
Court
Kind of Case
Year Filed
Result or Status (if you know)
7. I have received a Final Protective Order against the same respondent that expired within one (1) year of the abuse
alleged in this petition, and which was issued for a period of at least six (6) months.
☐ Date issued ☐ Date expired
☐ Location where issued
8. Describe all past injuries the respondent has caused the victim, and give date, if known
9. The respondent owns or has access to the following firearms:
10. I want the court to order the respondent: (NOTE: Petitioner need not give an address if doing so risks further abuse)
☐ NOT to abuse or threaten to abuse
☐ NOT to contact, attempt to contact, or harass
☐ NOT to go to the residence(s) at
☐ NOT to go to the school(s) at
☐ NOT to go to the child care provider(s)
☐ NOT to go to the work place(s) at
CC-DC-DV-001 (Rev. 06/2021) Page 2 of 3
PETPR
vs.
Respondent
Petitioner
City/County/State
Name(s)
Name(s)
Address
Name of school and address
Name of child care provider and address
Name(s)
Case No.
☐ To leave the home at
and give possession of the home to
The name(s) on the deed or lease are:
☐ To turn over firearm(s) to a law enforcement agency.
☐ To go to counseling for ☐ domestic violence ☐ drug/alcohol ☐ other
☐ To pay money as Emergency Family Maintenance (may be taken from respondent's paycheck).
11. I also want the court to order:
☐ Custody of
be granted to
☐ Use and possession of the following jointly-owned vehicle be granted to
☐ Temporary possession of the pet(s)
be granted to
☐ In the final order, the following additional relief necessary to protect
from abuse:
12. (Fill in only if you are seeking Emergency Family Maintenance.) The respondent has the following financial
resources:
Income from employment in the amount of $ every ☐ week ☐ 2 weeks ☐ month
☐ other
Source of employment income
Income from other source
The respondent also owns the following property of value: Automobile(s) $
Home $ Bank Account(s) $
Other:
I solemnly affirm under the penalties of perjury that the contents of this document are true to the best of my knowledge,
information, and belief.
☐ I have filled in the Addendum (Description of Respondent), CC-DC-DV-001A
NOTE
If you believe that you have been a victim of abuse and that there is a danger of serious and immediate injury to you,
you may request the assistance of a police officer or local law enforcement agency.
The law enforcement officer must protect you from harm when responding to your request for assistance and may, if
you ask, accompany you to the family home so that you may remove clothing and medicine, medical devices, and other
personal effects required for you and your children, regardless of who paid for them.
You are entitled to request that the address and telephone number of a victim, a complainant, or a witness be considered
for shielding at the filing of this application.
NOTICE TO CUSTODIAN: A person who places in a judicial record identifying information relating to a witness
shall give the custodian written or electronic notice that such information is included in the record, where in the record
that information is contained, and whether that information is not subject to remote access under this Rule, Rule 1-
322.1, Rule 20-201, or other applicable law. Except as federal law may otherwise provide, in the absence of such notice
a custodian is not liable for allowing remote access to the information.
CC-DC-DV-001 (Rev. 06/2021) Page 3 of 3
PETPR
vs.
Respondent
Petitioner
Date
Petitioner
Address
Name(s) of child(ren)
Name
Name
Description of vehicle
Name and description
Name
Person eligible for relief
Estimated value
Estimated value
Estimated value
Name and address of source and amount(s) received
Name and address of source and amount(s) received
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CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR Located (Maryland Judiciary)

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Completed 10 March 2022

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