100-00247SA - Complaint for Order Against Sexual Assault (11/2018) Page 1 of 1
COMPLAINT FOR ORDER AGAINST SEXUAL ASSAULT
Plaintiff’s Information:
Name: __________________________________________ Date of Birth: _______________________
Name(s) of minor child(ren): _____________________ _______________________
_____________________ _______________________
Defendant’s Information:
Name: __________________________________________ Date of Birth: _______________________
Address: ______________________________________________________________________________
Relationship of the Parties:
☐ Married to each other ☐ Live in same residence (current or past)
☐ Divorced from each other ☐ Sexual relationship (current or past)
☐ Dating each other (current or past)
☐ Other (describe relationship) ___________________________________________________________
☐ Family members (describe relationship) __________________________________________________
Other Civil/Probate/Juvenile/Criminal Court Proceedings or Orders Involving These Parties:
Proceeding: ☐ Pending Order ☐ Existing Order
Name of Court: County: _______________ State: ______ Attorney: __________________________
I. SEXUAL ASSAULT
☐ 1. On or about ______________________, the Defendant sexually assaulted the Plaintiff or the
Plaintiff's child(ren) by doing one or more of the following:
☐ lewd and lascivious conduct ☐ lewd and lascivious conduct with a child
☐ sexual assault ☐ aggravated sexual assault
☐ use of a child in a sexual performance
☐ consenting to a sexual performance and Plaintiff was the victim of the offense
☐ 2. On ________________________, the Defendant was convicted of sexually assaulting the Plaintiff.
II. REQUEST FOR RELIEF
The Plaintiff requests the Court:
☐ Order the Defendant to stay away from ________________________________________________
☐ Other: ___________________________________________________________________________
___________________________________________________________________________
☐ I am asking for an emergency order before the Defendant is notified and a hearing is held because:
_________________________________________________________________________________
_________________________________________________________________________________
The facts to support this request for protection order can be found on Plaintiff’s accompanying affidavit.
Dated
_____________________________ ___________________________________
Signature of Plaintiff/Attorney
