Fillable Domestic Violence Petition for Protective Order Confidential Information (Central Council Tlingit and Haida Indian Tribes of Alaska)

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Domestic Violence Petition for Protective Order Confidential Information (Central Council Tlingit and Haida Indian Tribes of Alaska)

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Domestic Violence
Please find included in the packet:
Petition for Protective Order
Confidential Information Form
Chapter 12 Family Safety
Domestic Violence hearings will be private and closed. Only persons the CCTHITA Court
and the family finds to have a legitimate interest in the proceedings may attend.
Submitting your Petition:
1. The CCTHITA Tribal Court will set a hearing date once the Petition for
Protective Order is submitted.
2. A 20 Day Ex Parte Protective Order will be done by the Judge of the Tribal
Court. The Tribal Court will then submit to the State of Alaska Court where a
State Court number will be assigned.
3. The State of Alaska Court will then submit to the State Troopers for service
on the respondent.
Please contact the Court Clerk at the number provided below for any questions or
concerns.
Central Council Tlingit & Haida Indian Tribes of Alaska
Tribal Court
320 W. Willoughby Avenue, Suite 300
Juneau, Alaska 99801
Telephone: 907-463-7165Toll Free: 1-800-344-1432 x7165
Fax: 1-866-532-3558
Central Council Tlingit and Haida Indian Tribes of Alaska
Juneau, AK
907-463-7165
1
In the Central Council Tlingit and Haida
Indian Tribes of Alaska Tribal Court
Juneau, Alaska
PETITION FOR PROTECTIVE ORDER
__________________________________,
Petitioner
V.
Court Docket Number: _________________
__________________________________,
Respondent
State Case Number: ____________________
PROTECTIVE ORDER PETITION
I, __________________________________________, swear or affirm under penalty of perjury
that all the information I provide in this Petition is true to the best of my knowledge and belief.
I am requesting (check all that apply):
20-day Protective Order. (This order, called an “ex parte” order, it can take effect
immediately without prior notice to the respondent.)
I understand that I can get a 20-day order without prior notice to the respondent.
However, the law requires that I tell the court about any efforts I have made to notify the
respondent.
I certify that:
I have not tried to notify the Respondent that I am filing this Petition.
I have notified or tried to notify the Respondent as follows (please explain):
__
Long-term protective order: one (1) year. (This order can only be issued after notice
to the Respondent and a Court hearing. Most provisions of this Order will last for one (1)
year. However, the provision that prohibits the respondent from committing domestic
violence will last indefinitely (until the court terminates it).
NOTE: If there is any chance you might need protection for more than 20 days, you should
request both a long-term order and a 20-day order. To do this, check both boxes.
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Central Council Tlingit and Haida Indian Tribes of Alaska
Juneau, AK
907-463-7165
2
I have been the victim of Domestic Violence by the Respondent as described below.
Include date of incident, place where incident occurred and injuries suffered, if any.
List the most recent incident first and specify whether weapons or children were involved.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Has the Respondent been involved in other instances of Domestic Violence?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
The Respondent is (check all that applies):
My Spouse My Former Spouse My Parent
My Grandparent My Child My Grandchild
My Brother My Sister My First Cousin
My Aunt My Uncle My Nephew
My Niece
A person with whom I presently have or previously had a dating or sexual relationship.
Someone who lives or has lived with me.
A person related, or formerly related, to me by marriage (for example, a stepparent or
stepchild)
Other (specify relationship): __________________________________________
I request an Order from the Court directing (check all that apply):
Respondent will not threaten or commit acts of Domestic Violence, stalking or
harassment.
Respondent will not telephone, contact or otherwise communicate directly or
indirectly with me.
Exception:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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Central Council Tlingit and Haida Indian Tribes of Alaska
Juneau, AK
907-463-7165
3
Respondent is to leave and/or stay away from my residence.
Exception:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
I request an Order directing a Peace Officer to accompany the Respondent to my
residence to remove Respondent’s essential personal belongings including:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Is Respondent residing with you?
Yes No
Is this residence is also used for business purposes:
Yes No
If yes, please describe the business: ____________________________________
The Title or Lease or Rental Contract for the residence is in whose name(s)?
_________________________________________________________________
(Note: The temporary possession of the residence may be given to the petitioner regardless of
ownership of the residence). CCTHITA Family Safety Code, Section 04.12.009 (A) (3))
Respondent is to stay away from, and not telephone, or go to the following locations:
My School or Child’s School (Name of School and Address):
__________________________________________________________________
__________________________________________________________________
My Place of Employment (Name of Employer and Address):
__________________________________________________________________
__________________________________________________________________
Other (please list below):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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Central Council Tlingit and Haida Indian Tribes of Alaska
Juneau, AK
907-463-7165
4
The following places frequented by me or by the member of my household
listed below:
Place & Address: Household Members:
Exception:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Respondent not to enter or follow a vehicle in my possession or occupied by me.
I am given temporary possession and use of the following, regardless of ownership:
The vehicle and all keys to it. Vehicle license number: ______________________
Vehicle description: _________________________________________________
I request that a Peace Officer to accompany me to my residence to ensure that I
safely obtain possession of the residence and any vehicle or personal items which the
court gives temporary possession of to me.
List of Items:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Respondent not to possess or use controlled substances.
Respondent is prohibited from destroying or defacing regalia or at.oow (cultural
objects).
I am a Tribal Citizen:
Yes No
Tribe: ____________________________________________________________
The Respondent is a Tribal Citizen:
Yes No
Tribe: ____________________________________________________________
There are children in my household:
Yes No
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Central Council Tlingit and Haida Indian Tribes of Alaska
Juneau, AK
907-463-7165
5
Are any of these children enrolled or eligible to be enrolled with the Central Council Tlingit and
Haida Indian Tribes of Alaska?
Yes No
Children:
I request the court to award me temporary physical custody of the minor child(ren)
named below:
Child’s Name: ________________________________________________________
Date of Birth: ________________________________________________________
Relationship to Petitioner: _______________________________________________
Relationship to Respondent: _____________________________________________
Child’s Name: ________________________________________________________
Date of Birth: ________________________________________________________
Relationship to Petitioner: _______________________________________________
Relationship to Respondent: _____________________________________________
Child’s Name: ________________________________________________________
Date of Birth: ________________________________________________________
Relationship to Petitioner: _______________________________________________
Relationship to Respondent: _____________________________________________
I currently have the child(ren):
Yes No
The child (ren) and I have lived in Alaska for the past six (6) months.
Yes No
There is a current Custody Order over one or more of the children.
Yes No Do Not Know
If yes, please provide information about each order below:
Child’s Name: _____________________________________________________
State Issued: _______________________________________________________
Date of Order: _____________________________________________________
The Order granted Custody to: ________________________________________
Child’s Name: _____________________________________________________
State Issued: _______________________________________________________
Date of Order: _____________________________________________________
The Order granted Custody to: ________________________________________
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Central Council Tlingit and Haida Indian Tribes of Alaska
Juneau, AK
907-463-7165
6
Child’s Name: _____________________________________________________
State Issued: _______________________________________________________
Date of Order: _____________________________________________________
The Order granted Custody to: ________________________________________
I request an Order directing a Peace Officer to assist me in obtaining the child(ren)
from: ________________________________________________ who now has them.
Visitation:
I understand the Court may only grant visitation to the Respondent if my safety and the
safety of the child(ren) can be protected. If the Court considers visitation, these are my
safety concerns:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Child Support:
The Court finds that a Minor Child is in the care of the Petitioner and the Respondent has an
independent legal obligation to support the Minor Child and/or the Petitioner. The Court
orders that:
The matter be referred to the State of Alaska Child Support Enforcement Division for
establishment of a child support order, or
I request that the Court order the Respondent to pay Child Support to me for the child
(ren) named during the period I have temporary physical custody of them.
Amount of Child Support granted: _______________________________________
Payable to: __________________________________________________________
Beginning: __________________________________________________________
Other: ______________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Financial Information for the Respondent:
Main Employer: ___________________________________________________
Occupation: _______________________________________________________
Income: __________________________________________________________
How many years at present job: ________________________________________
2
nd
Employer: ______________________________________________________
Income: __________________________________________________________
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Central Council Tlingit and Haida Indian Tribes of Alaska
Juneau, AK
907-463-7165
7
Other cases pending in Tribal Court or State Court:
Please list any other court cases in either the Tribal Court or State Court involving you or
the Respondent.
Include information concerning the type of case (for example, divorce or child custody,
or domestic violence criminal cases) and the approximate date the case was filed or
resolved.
_______________________________________________________
I request that the following be included in a Long-Term Protective Order.
I understand that these requirements cannot be included in the 20-day order.
I request that the Court direct:
Respondent not to use or possess a deadly weapon (including a firearm).
Respondent to surrender any firearms owned or possessed by the Respondent.
Respondent to reimburse the person named below for expenses associated
with the Domestic Violence (such as medical expenses, counseling, shelter, and
repair or replacement of damaged property) as described below. Reimbursement
may be in the form of money, subsistence foods or other appropriate reparations.
Pay to: ___________________________________________________________
Type of Expense: ___________________________________________________
Reparations: _______________________________________________________
Pay to: ____________________________________________________________
Type of Expense: ____________________________________________________
Reparations: ________________________________________________________
Respondent is to pay for the costs
and fees associated with bringing this action, in the amount of $ payable to:
_________________________________________________________________
Respondent to enroll in and complete, at Respondent’s expense:
A program for the rehabilitation of perpetrators of domestic violence.
A treatment program for the abuse of alcohol.
A treatment program for the abuse of controlled substances.
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Central Council Tlingit and Haida Indian Tribes of Alaska
Juneau, AK
907-463-7165
8
Withhold a portion of the benefits and services available to Respondent that are
directly related to being a citizen of the Central Council Tlingit and Haida Indian Tribes
of Alaska, including but not limited to educational scholarships, vocational training,
and/or general assistance.
Recommend to the Central Council Tlingit and Haida Indian Tribes of Alaska that the
Respondent be disenrolled.
Respondent to complete community work service with any community service
organization, including the Central Council Tlingit and Haida Indian Tribes of Alaska’s
Traditional Foods program.
The agency where Respondent will perform community service is:
__________________________________________ __________.
Other relief necessary to protect the safety of petitioner or any other family or
household member.
Please explain:
Personal Information about Respondent and Petitioner:
Please complete the Confidential Law Enforcement Information Sheet (attached).
If this Protective Order is granted, I request that the Order be placed on the Alaska Statewide
Protection Order Registry:
Yes No
Date Petitioner’s Signature
Print Name
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Central Council Tlingit and Haida Indian Tribes of Alaska
Juneau, AK
907-463-7165
9
Subscribed and sworn to or affirmed before me at , Alaska
on .
Date
Clerk of Court, Notary Public or Other Person
Authorized to Administer Oaths
(SEAL) My commission expires:
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CONFIDENTIAL LAW ENFORCEMENT INFORMATION SHEET
Notice to Petitioner
: You must supply the respondent's name and birth date, if known. Give as much information
as possible. This information will NOT
be given to the respondent.
Notice to Law Enforcement
: This information is confidential and supplied to assist you in serving the protective
order. After serving (or failing to serve) the order, notify petitioner and complete the return of service section on
the DV-125.
A. PETITIONER INFORMATION
Full name:
Date of birth: Petitioner is a child.
Petitioner’s residence address:
Is this the address respondent is to stay away from?
Yes No
Do you want to be notified when respondent is served?
Yes No
Contact phone(s): home
work cell msg
B. RESPONDENT INFORMATION
Full name:
Nicknames: Respondent is a child.
Residence Address:
Is this the address respondent is to stay away from?
Yes No Last four digits of SSN
Other Addresses:
Contact phone(s): home
work cell msg
Where is respondent now (what street address)? Other information about respondent:
Sex Race
*Da
te of Birth*
HT WT
Hair Eyes State ID / Driver’s Lic. # ST
Other Identifiers
(facial hair, piercings, scars, tattoos, marks, etc.)
Friends / relatives / phone numbers / hangouts:
Hazards at respondent’s home (dogs, traps, guns):
Describe respondent’s house:
log frame apartment single family duplex
1 story 2 story 3+ story main color trim color
Garage:
separate attached none 4x4 needed to access address? Y N
Respondent’s employer
Employer address
Work phone
Work hours
Respondent’s position
Supervisor
Respondent’s vehicle information
Make
Model
Plate No.
State
Year
van pickup canopy camper
toolbox car 2 door 4 door
SUV other
Other vehicles respondent is known to drive:
C. OFFICER SAFETY INFORMATION
Previous contact with police by respondent?
No Yes Explain:
Any threats by respondent toward petitioner, family, police? Describe:
Weapons accessible to respondent (pistol, rifle, knife, other):
Expected mental state or history of respondent (include alcohol or drug use):
Is a divorce or other legal action pending that involves the respondent (child custody, eviction, bankruptcy,
repossession of property)?
Draw a map on the back of this form if it will help law enforcement.
DV-127 (5/10)(cs) Civil Rule 65.1
CONFIDENTIAL LAW ENFORCEMENT INFORMATION SHEET (DOMESTIC VIOLENCE OR STALKING)
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Domestic Violence Petition for Protective Order Confidential Information (Central Council Tlingit and Haida Indian Tribes of Alaska)

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Completed 18 November 2021

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