Fill - Free fillable COVER SHEET STATE OF ARKANSAS CIRCUIT COURT: DOMESTIC (Administrative Office of the Courts) PDF form

COVER SHEET

STATE OF ARKANSAS

CIRCUIT COURT: DOMESTIC RELATIONS

6/1/2017

The domestic relations reporting form and the information contained herein shall not be admissible as

evidence in any other court proceeding or replace or supplement the filing and service of pleadings, orders,

or other papers as required by law of Supreme Court Rule. This form is required pursuant to Administrative

Order Number 8. Instructions are located at www.courts.arkansas.gov.

County: District: Filing Date:

Judge: Division: Case ID:

Type of Case (select only one):

□ (AN) Annulment (marriage date: )

□ (CT) Contempt-Domestic Relations

□ (CS) Custody

□ (DV) Divorce (marriage date: )

□ (FJ) Foreign Judgment-Domestic Relations

□ (DA) Order of Protection

□ (PT) Paternity

□ (SM) Separate Maintenance (marriage date: )

□ (SS) Support (OCSE)

□ (ST) Support-Private (non-OCSE)

□ (SU) Support-UIFSA

□ (VI) Visitation

Does this case involve the custody or support of minor children? □ Yes □ No

If yes, also file the completed Confidential Information Sheet.

Plaintiff

Defendant

Last Name

Suffix

First Name

DL/State ID

Address

City, State, ZIP

Phone

Email

Self-represented

□ Yes □ No

Self-represented

□ Yes □ No

DOB

Interpreter

needed?

□ Yes:

□ No

(language)

Interpreter

needed?

□ Yes:

□ No

(language)

Attorney of Record: Bar #:

For the: □ Plaintiff □ Defendant Email Address:

Related Case(s): Judge: Case ID(s):

Manner of filing: □ (MFO) Original □ (MFR+case type) Re-open

□ (MFT) Transfer □ (MFF) Reactivate

CONFIDENTIAL INFORMATION FOR USE ONLY BY THOSE AUTHORIZED BY

Arkansas Code

Annotated 9-14

-205

Custodial Parent/Custodian:

Residential Addr:

(Street) (City) (St) (Zip)

Mailing Addr:

(Street or PO Box) (City) (St) (Zip)

Phone Numbers: (Home) (Cell)

Social Security Number: DOB:

Driver’s License Number: (State) (Number)

Employer’s Name or Business:

Address:

(Street or PO Box) (City) (St) (Zip)

_________________________________________________________________________________________

Non-Custodial Parent:

Residential Addr:

(Street) (City) (St) (Zip)

Mailing Addr:

(Street or PO Box) (City) (St) (Zip)

Phone Numbers: (Home) (Cell)

Social Security Number: DOB:

Driver’s License Number: (State) (Number)

Employer’s Name or Business:

(Street or PO Box) (City) (St) (Zip)

___________________________________________________________________________________________

Children’s Names and Birth Dates:

Name: DOB: SSN:

Print or Type preparer’s name:

This is confidential information and shall not be released to any person or entity except as authorized by law. The information is required to be submitted by the parties or their attorneys pursuant to ACA 9-14-205

AOC Form 35

6/2005

Docket Number

Style of Case

OCSE Case Number

IN THE CIRCUIT COURT OF BENTON COUNTY, ARKANSAS

Petitioner's Home Address:

(Leave blank if the Respondent does not know where you live)

1. ________________________________________________ ______________________________________________________

Petitioner's First, Middle, and Last Name

______________________________________________________

Date of Birth ______________ Sex _____ Race _____ Petitioner's Workplace and Address:

(Leave blank if the Respondent does not know where you work)

______________________________________________________

VS. Case No. DR ___________________

______________________________________________________

Respondent's Home Address:

2. ________________________________________________ ______________________________________________________

Respondent's First, Middle, and Last Name

______________________________________________________

Date of Birth ______________ Sex _____ Race _____ Respondent's Workplace and Address:

______________________________________________________

PETITION FOR ORDER OF PROTECTION

3. ____ I am the Petitioner and am: ____ at least 18 years of age; (or) ____ under 18 but emancipated.

____ I am filing on behalf of myself.

____ I am filing on behalf of a family or household member who is:

____ a minor: (full name(s) _______________________________________________________________________________

____ an adjudicated incompetent person: (full name) ____________________________________________________________

____ The Respondent is: ____ at least 18 years of age; (or) ____ under 18 but emancipated.

____ I am an employee or volunteer of a domestic violence shelter or program, and I am filing on behalf of a minor.

4. The Respondent and Petitioner (or Victim if filing on behalf of a minor or incompetent person): (check all that apply)

____ are spouses (date of separation ____________) ____ have or have had a child in common

____ are parent and child (Respondent is Victim's ____________) ____ currently reside together or cohabitate

____ are former spouses (date of divorce ___________________) ____ formerly resided together or cohabitated (date of sep. ______)

____ are related by blood (Respondent is Victim's ____________) ____ are/were in a dating relationship from ________ to ________

5. If an Order of Protection for children is requested, provide the following information:

Name(s) of Child(ren) Date of Birth Sex Race Address/School Relationship to Parties

6. If an Order of Protection for pets is requested, please identify each by name and breed: ________________________________________

______________________________________________________________________________________________________________

7. ___ The Respondent has committed domestic abuse to the petitioner or victim by the acts described in the attached affidavit.

8. ___ The Respondent is scheduled to be released from incarceration within 30 days. Upon the Respondent's release, there will be immediate

and present danger of domestic abuse to me and/or the Victim(s).

9. Have you reported abuse to law enforcement? ____ Yes ____ No Has Respondent been arrested? ____Yes ____No

10. Did Respondent use or threaten to use a weapon? ____ Yes ____ No If yes, indicate the type of weapon: ______________________

11. Petitioner requests that the court issue an Ex-Parte Order of Protection with the following provisions (check all that apply):

(a) ____ Excluding the Respondent from a shared residence or from the residence of the Petitioner or Victim(s).

Address of the Residence: _______________________________________________________________________________

(b) ____ Excluding the Respondent from the place of business, employment, school or other location of the Petitioner or

Victim(s).

Employment Address: __________________________________________________________________________________

School Address: _______________________________________________________________________________________

Other: _______________________________________________________________________________________________

(c) ____ Civil Standby Requested: Petitioner or Respondent (circle one)

Address where the Civil Standby is needed: _________________________________________________________________

(d) ____ Awarding temporary custody of the minor children of the Petitioner and Respondent as follows:

Child's Name Person to receive custody

12. Is there a current/pending custody order? ____ Yes ____ No

If yes, give Case No. _______________________ County/State __________________________ Judge __________________________

Who has legal custody? ____ Petitioner ____ Respondent Who has physical custody? ____ Petitioner ____ Respondent

Is there a closed or pending divorce action between the parties? ____ Yes ____ No

If yes, give Case No. _______________________ County/State __________________________ Judge __________________________

13. Have you previously filed a petition for order of protection against the Respondent? ____ Yes ____ No

If yes, give Case No. _______________________ County/State __________________________ Judge __________________________

14. Do you, any witnesses, and/or Respondent require an interpreter at the protective order hearing? _____ Yes ____ No.

What language? ________________________________________

Please initial the following statements confirming you have read them and understand them.

15. I understand that once this petition is filed in the Circuit Clerk’s Office I will be assigned a Judge who will review my petition and

determine eligibility. The Judge has the ability to issue a Temporary Protective Order that includes a hearing date to be held within 30 days

OR issue an Order to Appear in court OR dismiss the petition all together. ________

16. I understand I am required to attend any hearing date that is set by the Judge. If I do not attend the hearing, I understand that a warrant can

be issued for my arrest and I can be required to pay all filing fees. ________

17. I understand if the Judge awards a Temporary Order of Protection, the order will not be in effect until the Respondent has been served with

a copy of the petition, affidavit and order. ________

18. I understand that if the Respondent violates the Order of Protection I should contact law enforcement immediately. To ensure proper

enforcement, I should not initiate contact with Respondent. ________

19. I understand that I am not required to have an attorney but that without legal representation, I must be prepared to provide testimony and

possible cross examination. ________

20. I understand that the Respondent has a right to attend the hearing and protest the allegations listed in this petition. Based on testimony, the

Judge may dismiss the petition, amend it or grant a Final Order of Protection for a minimum of 90 days to a maximum of 10 years.

________

21. I understand that once this petition is filed with Circuit Clerk’s Office I cannot request dismissal of a Temporary Protection Order or Order

to Appear until the hearing. ________

22. I understand that if there are errors in my petition/affidavit I would be required to come back to this office and correct the errors or the

petition/affidavit could be dismissed. If it is not dismissed and I have refused to return to make the required corrections it is possible any

orders that are issued would not be served on Respondent, therefore making them unenforceable. ________

I understand that once signed, this petition acts as a sworn affidavit and that if I intentionally provide any false

information, I may be held liable financially and/or criminally. I also understand that I am required to attend the

hearing, and that if I fail to appear on the hearing date, the court has the authority to charge me $215.00 and/or issue

a Body Attachment Warrant for my arrest.

_____________________________________

Petitioner's Signature

AFFIDAVIT

The Petitioner, under oath, swears that the facts stated in the above Petition are true according to the Petitioner's best

knowledge and belief.

__________________________ _________________________________________

Date Petitioner's Signature

STATE OF ARKANSAS )

COUNTY OF BENTON )

Subscribed and sworn to before me this _______ day of _______________________, 20____.

____________________________________________

Notary Public

My Commission Expires:

(SEAL)

Page ___ of ___

IN THE CIRCUIT COURT OF BENTON COUNTY, ARKANSAS

_______ DIVISION

________________________ PETITIONER

VS. CASE NO. ________________

________________________ RESPONDENT

AFFIDAVIT ACCOMPANYING PETITION FOR DOMESTIC ORDER OF

PROTECTION

I, ______________________________, Petitioner in the above named Order of

Protection Case having been duly sworn, depose and state the following under penalty of

perjury:

1. I am the Petitioner in the above-captioned case for a Petition for an Order of Protection

against the named Respondent.

2. In good faith, I believe I am entitled to an Order of Protection against the Respondent, and I

submit this Affidavit in accordance with Arkansas Code Annotated § 9-15-201(e) (2).

3. The specific facts and circumstances that have led to the filing of this Order of Protection are

as follows:

___________________________________________________________________________

Page ___ of ___

___________________________________________________________________________

Page ___ of ___

4. These facts, along with the facts alleged in my accompanying Petition constitute my request for an

Ex-Parte Order of Protection and Final Order of Protection.

5. I request that an Ex-Parte Temporary Order of Protection and a Final Order of Protection be

entered granting me the following relief: (check all that apply)

6. ____ Exclude the respondent from a shared residence or from the residence of the petitioner or

victim. Address of residence:___________________________________________________

___________________________________________________________________________

7. ____ Exclude the petitioner’s address from notice to the respondent.

8. ____ Exclude the respondent from the place of business, employment, school, or other location of

the petitioner or victim. Address of:

Place of business: ____________________________________________________________

Employment: _______________________________________________________________

School: ____________________________________________________________________

Other (identify): _____________________________________________________________

9. ____ Prohibit the respondent, directly, indirectly or through an agent, from contacting the

petitioner or victim.

10. ____ Award temporary custody or establish temporary visitation rights of minor children as

follows:

Child’s Name/Person to Receive Custody:

11. ____ Direct the care, custody, or control of the following pets: ___________________________

______________________________________________________________________________

12. ____ Require the respondent to pay temporary child support.

13. ____ Require the respondent to pay temporary spousal support.

Page ___ of ___

14. ____ Require Respondent to pay any associated costs including my attorney fees.

15. ____ Although Respondent is the account holder of the following wireless telephone number(s), I

and/or the minor children in my care are the primary users of these phone numbers:

_________________________ _________________________ _________________________

I am requesting that the Court prohibit Respondent from terminating these accounts until the

Court can consider whether an order is warranted transferring the billing responsibility for, and

the rights to, the wireless telephone number(s).

16. I further request any other relief as the court deems necessary or appropriate pursuant to Ark.

Code Ann. § 9-15-205 (8)(A).

17. I request that a hearing be set on this matter and that notice and order to appear be issued to

Respondent.

__________________________________

PETITIONER

__________________________________

DATE

STATE OF ARKANSAS )

COUNTY OF __________ )

SUBSCRIBED AND SWORN to before me, the below named officer, this ____ day of

_________________, 20____.

______________________________________

NOTARY PUBLIC

MY COMMISSION EXPIRES:

(SEAL)

BENTON COUNTY SHERIFF’S OFFICE

Service Location/Direction Information

MARK FOR OFFICER SAFETY: RESPONDENT HAS ACCESS TO WEAPONS I.E. GUNS, KNIVES

Please answer the following to the best of your knowledge; it will help the deputy serve the Order.

NOTE: Information on this form is for Law Enforcement use only.

PETITIONER’S NAME:____________________________________________________________

Petitioner’s Date of Birth________________________________________Sex:______________

Petitioner’s Home Phone Number:______________Work:______________Cell:_____________

RESPONDENT’S NAME:___________________________________________________________

Respondent’s Date of Birth:______________________________________Sex:______________

Respondent’s Physical Description: Race______Hgt______Wgt______Hair_______Eye_______

Respondent’s Home Phone Number:_____________Work:______________Cell:____________

Respondent’s Address AND Directions:______________________________________________

______________________________________________________________________________

Respondent’s Employment AND Address:____________________________________________

______________________________________________________________________________

Respondent’s Work Hours:__________________________Days:__________________________

Respondent’s Nearest Relative:____________________________________________________

Relationship:_______________________________Phone Number:_______________________

Address AND Directions:__________________________________________________________

______________________________________________________________________________

Additional Information on Respondent’s Location:_____________________________________

______________________________________________________________________________

Respondent’s Vehicle Make:__________Model:__________Color:__________Tag #:_________

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