Fillable Connecticut APPLICATION FOR RELIEF FROM ABUSE

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Connecticut APPLICATION FOR RELIEF FROM ABUSE

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The Connecticut APPLICATION FOR RELIEF FROM ABUSE form is 2 pages long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for State of Connecticut/Department of Administrative Services

BROWSE STATE OF CONNECTICUT/DEPARTMENT OF ADMINISTRATIVE SERVICES (CT) FORMS

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Page 1 of 2 (continued on page 2)
Your home/residence address* (See Note below)
APPLICATION FOR RELIEF FROM ABUSE
JD-FM-137CO New 4-20
C.G.S. §§ 29-28, 29-32, 29-33, 46b-15, 52-231a; P.A. 17-163; E.O. 7T
Respondent is (Select all that apply)
A caretaker who is providing shelter in his or her residence to a
(Give the docket number and court location, if known)
*Note: Any addresses you provide will be included in the court file and will be provided to the Respondent. These addresses will also
tell the court which law enforcement agencies must be notified if the court issues a restraining order. If you believe that giving
out your home, work, or school address would put you and/or your children's health, safety or liberty in danger, you may use a
mailing address that is different from your home or work address, including the address for the Safe at Home address
confidentiality program, if applicable, but it is important to note that doing so may limit which law enforcement agencies receive
notice of the order. You may also file a Request for Nondisclosure of Location Information form JD-FM-188CO (which requires a
mailing address) with the Clerk's Office.
Information About the Respondent (Person the application is filed against)
Judicial District of
Court location (number, street, town, zip code)
Docket number
Your name (Applicant) (Last, first, middle initial) Date of birth (mm/dd/yyyy) Sex (M/F)
Race
Your mailing address (Number, street)* (See Note below)
Town State Zip Code
Same as mailing address
Town State Zip Code
Your work address* (See Note below)
Town State Zip Code
Respondent's name (Last, first, middle initial) Date of birth (mm/dd/yyyy) Sex (M/F)
Race
Respondent's address (Number, street)
(Town) (State) (Zip Code)
Respondent's telephone number
Other identifiers (Examples include height, weight and approximate age)
My spouse or a person I have a civil union with
A person who is also the parent of my dependent child or
Parent of my child
My parent
My child
A person related to me by blood or marriage
A person I reside or resided with
A person I have (or recently had) a dating relationship with
Select here if you know about any other Protective Order or Restraining Order that exists involving you or the Respondent.
Docket number Court location
Select here if a dissolution of marriage (divorce), dissolution of civil union, custody or visitation action exists involving you and the Respondent.
Docket number Court location
Someone I have cohabited with as an intimate partner
(romantic, spousal, or sexual relationship while living together)
If you are seeking additional orders of maintenance, check here
(If you check this box, you must complete JD-FM-233CO,
Request for Orders of Maintenance and submit it as part of
your application)
(If you check this box, you must complete JD-FM-233CO, Request
for Orders of Maintenance and submit it as part of your application)
If you are seeking additional orders of maintenance, check here
(Give the docket number and court location, if known)
Optional to Applicant (If you choose to answer, select the appropriate boxes below)
1. Does the Respondent hold a permit to carry a pistol or revolver? ……………………
3. Does the Respondent possess one or more firearms? …………………………………
UnknownNoYes
4. Does the Respondent possess ammunition? ……………………………………………
If you think you need more security when you are in court for your relief from abuse hearing, contact the Clerk's Office or the Court Service
Center in the court where your hearing is scheduled.
Yes No Unknown
Yes No Unknown
UnknownNoYes
2. Does the Respondent hold an eligibility certificate for a pistol or revolver, a long gun
eligibility certificate, or an ammunition certificate? ………………………………………
children in common and we all live together.
person 60 years of age or older
*APPRFA*
APPRFA
COURT USE ONLY
STATE OF CONNECTICUT
SUPERIOR COURT
www.jud.ct.gov
For information on ADA accommodations,
contact a court clerk or go to: www.jud.ct.gov/ADA.
Instructions:
This Application and any documents accompanying it may be submitted to the clerk
by e-mail or fax. The appropriate e-mail address or fax number may be located at
www.jud.ct.gov. The clerk will return the proper papers to you at the e-mail address
or fax number from which the Application was received.
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Page 2 of 2
JD-FM-137CO New 4-20
Request For Ex Parte (Immediate) Relief (Select if this applies)
The Respondent not contact me in any manner, including by written, electronic or telephone contact, and not contact my home,
workplace or others with whom the contact would be likely to cause annoyance or alarm to me. (CT05)
I have been subjected to a continuous threat of present physical pain or physical injury, stalking or a pattern of threatening, by
the Respondent named above as explained more fully in my attached Statement of Facts.
danger to me and/or my minor children and/or animals owned or kept by me.
Application for Relief From Abuse
Name
(Last, first, middle initial)
Date of birth
(mm/dd/yyyy)
Date of birth
(mm/dd/yyyy)
Sex
(M/F)
Sex
(M/F)
Name
(Last, first, middle initial)
CT01
CT03
CT05
CT14
CT16
CT19
CT31
CT20
CT21
CT22
Applicant's name Respondent's name Docket number
1. I ask that the court order the following conditions: (Select all that apply)
The Respondent not assault, threaten, abuse, harass, follow, interfere with, or stalk me. (CT01)
The Respondent stay away from my home or wherever I shall reside. (CT03)
The Respondent may return to the home one time with police to retrieve belongings. (CT14)
The Respondent stay 100 yards away from me. (CT16)
That the order protect my minor children. (CT19)
That the order protect animals owned or kept by me. (CT31)
2. I ask that the court make the following temporary child custody and visitation orders:
Award me temporary custody of the following minor child(ren) who is (are) also the child(ren) of the Respondent.
1
2
3
4
5
6
With visitation as follows:
Without visitation rights to the Respondent.
3. I ask that the court order the following: (further order)
4. I am in school and I ask that a copy of the restraining order, if it is granted, be sent to my school
6. I ask that the court order Ex Parte (immediate) relief because I believe there is an immediate and present physical
Name
(Last, first, middle initial)
Date of birth
(mm/dd/yyyy)
Date of birth
(mm/dd/yyyy)
Sex
(M/F)
Sex
(M/F)
Name
(Last, first, middle initial)
1
2
3
4
5
6
Name of school Fax number of school
Address of school (Number, street)
Town State Zip Code
If I have moved out of the home of the Respondent, the Respondent shall permit me to return to the Respondent's home on one
occasion, with police, to retrieve my belongings. (CT15)
CT15
5. My minor child or children for whom I am also asking for protection is/are in school and I ask that a copy of the restraining
Name of school Fax number of school
Address of school (Number, street)
Town State Zip Code
order, if it is granted, be sent to my child's or children's school (attach additional sheets if necessary).
Date signedEnter your name as your signature
The representations made in this document are
made under the penalty of false statement.
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Connecticut APPLICATION FOR RELIEF FROM ABUSE

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Completed 11 April 2020

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