11. Have YOU ever been arrested or charged with domestic violence, or any other crime committed
against your spouse, partner, or child(ren)? Yes No
If yes, WHEN and where?
12. To your knowledge, has the ADVERSE PARTY ever been arrested or charged with domestic
violence, or any other crime committed against his/her spouse, partner, or child(ren)?
Yes No I don’t know If yes, WHEN and where?
13. An emergency exists, and I need a TEMPORARY ORDER FOR PROTECTION AGAINST
DOMESTIC VIOLENCE issued immediately, without notice to the Adverse Party, to avoid
irreparable injury or harm. I request that it include the following relief, and any other relief the
Court deems necessary in an emergency situation. (Please check all the choice(s) that may apply
(A) Prohibit the Adverse Party, either directly or through an agent, from threatening,
physically injuring, or harassing me and/or the minor child(ren).
(B) Prohibit the Adverse Party from any contact with me whatsoever.
(C) Exclude the Adverse Party from my residence and order the Adverse Party to stay at
least 100 yards away from my residence.
(D) Obtain law enforcement assistance to accompany me to the following residence,
to accompany the Adverse Party to the following residence,
to obtain personal property.
(E) Grant temporary custody of the minor child(ren) to me.
(F) Order that custody, visitation, and support of the minor child(ren) remain as ordered in
the Decree of Divorce/Order entered in Case Number _______________________ in the
________________________________Court of the State of ______________________ .