Fillable Connecticut STATEMENT OF FACTS RELIEF FROM ABUSE form

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Connecticut STATEMENT OF FACTS RELIEF FROM ABUSE form

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The Connecticut STATEMENT OF FACTS RELIEF FROM ABUSE form form is 1 page long and contains:

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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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I, the person signing below, say under the penalty of false statement that I am the Applicant in this matter and state as follows:
(Explain for each incident: (1) what happened, (2) when it happened, (3) where it happened, and (4) who was there
when it happened.)
STATEMENT OF FACTS - RELIEF FROM ABUSE
JD-FM-138CO New 4-20
C.G.S. §§ 46b-15, 52-231a, P.B. § 25-57; E.O. 7T
Statement of Conditions From Which You Seek Relief
Statement Concerning Temporary Custody of Children
Select one of the following:
I am not asking for temporary custody of any minor child or minor children in this matter.
I am asking for temporary custody of my minor child or minor children in this matter.
(Fill out a Statement of Facts Concerning Children, form JD-FM-164CO, and send it to the clerk
along with this form and your filled out Application For Relief From Abuse, form JD-FM-137CO.)
Instructions to Person Applying for Relief from Abuse (Affiant):
This statement must be filled out completely and given to the clerk along with your filled out Application for Relief From Abuse, form JD-FM-137CO. Your
statement must include a statement of the conditions you seek relief from. Your statement must be true to the best of your knowledge and made under the
penalty of false statement. State if any arrest was made related to the incidents outlined in this statement.
Do not write on the back of this form.
If you need additional room, use another Statement of Facts - Relief From Abuse, form JD-FM-138CO. You must sign all pages.
If you are asking for temporary custody of your minor child or minor children, you must also fill out a Statement of Facts Concerning Children,
form JD-FM-164CO.
Name of applicant (Your name) Name of respondent (Person you want a restraining order against) Docket number (For court use only)
*AFFRFA*
AFFRFA
For Court Use Only
STATE OF CONNECTICUT
SUPERIOR COURT
www.jud.ct.gov
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 STATEMENT OF FACTS RELIEF FROM ABUSE form

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Completed 11 April 2020

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