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In the Central Council Tlingit and Haida Indian (Central Council Tlingit and Haida Indian Tribes of Alaska)

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U.S.A. forms for Central Council Tlingit and Haida Indian Tribes of Alaska

BROWSE CENTRAL COUNCIL TLINGIT AND HAIDA INDIAN TRIBES OF ALASKA (AK) FORMS

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Petition for Protective Order Tlingit & Haida Tribal Court
Page 1 of 8 320 W. Willoughby Ave. Ste 300
Juneau, AK 99801
Phone: 907-463-7165
Fax: 866.532.3558
In the Central Council Tlingit and Haida
Indian Tribes of Alaska Tribal Court
Juneau, Alaska
_________________________,
Petitioner
PETITION FOR PROTECTIVE ORDER
V.
Case No._______________________
_________________________,
Respondent
1. I am requesting (check all that apply)
☐ Ex-parte protective order: twenty (20) days.
I certify that I:
☐ Have not tried to notify the respondent that I am filing this petition.
☐ Have notified or tried to notify the respondent as follows: ________________
__________________________________________________________________
☐ Long-term protective order: one (1) year.
2. PETITIONER INFORMATION:
Full Legal Name: ___________________________________________________
Tribal Status:
☐ Enrolled in with T&H - Enrollment number: ___________
☐ Eligible to Enroll in T&H
☐ Enrolled in other Tribe – Name of Tribe: _______________________
☐ Not eligible for enrollment in any Tribe
Petition for Protective Order Tlingit & Haida Tribal Court
Page 2 of 8 320 W. Willoughby Ave. Ste 300
Juneau, AK 99801
Phone: 907-463-7165
Fax: 866.532.3558
Mailing Address: ___________________________________________________
Message Phone: ____________________________________________________
3. RESPONDENT INFORMATION:
Full Legal Name: ___________________________________________________
Tribal Status:
☐ Enrolled in with T&H - Enrollment number: __________
☐ Eligible to Enroll in T&H
☐ Enrolled in other Tribe – Name of Tribe: _____________________
☐ Not eligible for enrollment in any Tribe
Mailing Address: ___________________________________________________
Message Phone: ____________________________________________________
4. SPECIAL RELATIONSHIP: between Petitioner and Respondent (check all that apply)
☐ spouse ☐ former spouse ☐ related by blood or adoption ☐ have child(ren) with
☐ related or formerly related by marriage (a step-parent or step-child)
☐ lives or lived in the same household or facility
☐ have or had a dating or sexual relationship
☐ other (specify relationship) ______________________________________________
5. HOUSEHOLD MEMBERS (use additional pages if necessary):
Household Member #1
Full Legal Name: ___________________________________________________
Tribal Status:
☐ Enrolled in with T&H - Enrollment number: ___________
☐ Eligible to Enroll in T&H
☐ Enrolled in other Tribe – Name of Tribe: _______________________
☐ Not eligible for enrollment in any Tribe
Mailing Address: ___________________________________________________
Message Phone: ____________________________________________________
Petition for Protective Order Tlingit & Haida Tribal Court
Page 3 of 8 320 W. Willoughby Ave. Ste 300
Juneau, AK 99801
Phone: 907-463-7165
Fax: 866.532.3558
Household Member #2
Full Legal Name: ___________________________________________________
Tribal Status:
☐ Enrolled in with T&H - Enrollment number: ___________
☐ Eligible to Enroll in T&H
☐ Enrolled in other Tribe – Name of Tribe: _______________________
☐ Not eligible for enrollment in any Tribe
Mailing Address: ___________________________________________________
Message Phone: ____________________________________________________
6. OTHER PENDING OR RESOLVED CASES:
List any other court cases in any other 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.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
7. I request an order from the court directing (check all that apply)
☐ Respondent not to threaten to commit or committing acts of domestic violence, dating
violence, family violence, stalking, and sexual assault.
☐ Respondent is not to telephone, email, message, or otherwise communicate directly or
indirectly with Petitioner, Petitioner’s family, and their household members.
Exceptions (if any):_____________________________________________________
☐ Respondent to leave and stay away from Petitioner’s residence. Exceptions (if any):
________________________________________________________________________
Is the Respondent residing with you? ☐ Yes ☐ No
If yes, answer the following:
Address: __________________________________________________________
Is the residence also used for business purposes? ☐ Yes ☐ No
Petition for Protective Order Tlingit & Haida Tribal Court
Page 4 of 8 320 W. Willoughby Ave. Ste 300
Juneau, AK 99801
Phone: 907-463-7165
Fax: 866.532.3558
The title or lease for the residence is in the name of: _______________________
NOTE: Temporary possession of the residence may be given to the Petitioner
regardless of ownership of the residence. Tlingit & Haida Family Safety Code,
Section 04.13.010 (A) (3)
☐ Respondent is to stay away from and not go to the following locations:
☐ My school or Child’s school (name and address):
__________________________________________________________________
__________________________________________________________________
☐ My place of employment (name and address):
__________________________________________________________________
__________________________________________________________________
☐ The following places frequented by me or by the member of my household
listed below: (List name of place and address)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Exceptions (if any):
__________________________________________________________________
__________________________________________________________________
☐ Respondent not to enter a motor vehicle, airplane, ferry, or other propelled vehicle in
my possession or occupied by the Petitioner.
☐ I am given temporary possession and use of the following, regardless of ownership:
☐ Vehicle and all keys to it. Vehicle License Number: _____________________
Vehicle Description: ________________________________________________
☐ Essential personal items, Including: __________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
☐ A Law Enforcement Officer or Peace Officer to accompany ☐Petitioner(me) or
☐Respondent to assist with the following:
Petition for Protective Order Tlingit & Haida Tribal Court
Page 5 of 8 320 W. Willoughby Ave. Ste 300
Juneau, AK 99801
Phone: 907-463-7165
Fax: 866.532.3558
☐ possession of a residence, vehicle, or personal items in which the court gave
temporary possession of.
☐ a vehicle and personal items
☐ essential personal items
☐ Respondent not to use or possess a firearm or other deadly weapons.
☐ Respondent to surrender any firearm owned or possessed by the Respondent.
8. CUSTODY OF MINOR CHILDREN:
☐ I request that the Court grant me (Petitioner) temporary physical custody of the minor
child(ren) named below:
Child’s Name Date of Birth Relationship Petitioner/Respondent
__________________ _______________ ______________________________
__________________ _______________ ______________________________
__________________ _______________ ______________________________
__________________ _______________ ______________________________
The child(ren) currently live with ☐Petitioner ☐Respondent at ____________________
☐ A Law Enforcement Officer will need to accompany me to obtain the child(ren) from
________________________________________________________________________
Is there a custody order over one or more of the children? ☐Yes ☐No
If yes, provide name of child, name of court and court case number:
________________________________________________________________________
________________________________________________________________________
☐ 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
visitations, my concerns are:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Petition for Protective Order Tlingit & Haida Tribal Court
Page 6 of 8 320 W. Willoughby Ave. Ste 300
Juneau, AK 99801
Phone: 907-463-7165
Fax: 866.532.3558
9. ENTRY INTO NATIONAL CRIMINAL INFORMATION SYSTEM:
A copy of any protective order granted, may be entered into the designated computer
based criminal information system. Entry into the law enforcement information system
constitutes notice to all law enforcement agencies of the existence of the order. If this
protective order is granted.
SEPARATE ORDER FOR PREVENTION SERVICES
☐ Refer the respondent to a Tribally approved batterer’s prevention program.
☐ Refer the respondent to Individual mental health counseling with a counselor who has been
trained in the dynamics of domestic or family violence.
☐ Refer the respondent to group wellness activities.
☐ Prohibit the respondent from consuming controlled substances.
☐ Require the respondent to pay temporary support, which may be enforced with an income
withholding order, to the petitioner for a minor child that is in the care of the petitioner or
another caregiver if there is an independent legal obligation of the respondent to support the
petitioner or child.
☐ I request that the court finds that the minor child(ren) in this case of the petitioner and
the respondent has an independent legal obligation to support the Minor child(ren) as
follows:
☐ The Respondent to pay child support to me (petitioner) for the child(ren)
named above during the period I have temporary physical custody of them.
☐ I do not want child support at this time.
☐ Refer the parties to the Tribal Child Support Unit for services, including paternity and the
establishment of a permanent support order.
☐ Require the respondent to reimburse the petitioner or other person for expenses associated
with the dating violence, domestic violence, family violence, stalking and sextual assault,
including medical expenses, counseling, shelter, and repair or replacement of damaged
property.
Pay to Type of Expense Reparation
_________________ _______________________ ____________
Petition for Protective Order Tlingit & Haida Tribal Court
Page 7 of 8 320 W. Willoughby Ave. Ste 300
Juneau, AK 99801
Phone: 907-463-7165
Fax: 866.532.3558
_________________ _______________________ ____________
☐ Require the respondent to pay costs and fees incurred by the petitioner bringing the action.
☐ Respondent to pay to _______________________________ the costs and fees
associated with bringing this action in the amount of $______________________.
☐ Withhold a portion of or all of the respondent’s benefits and services which are directly
related to being a citizen of T&H, except that benefits to which a respondent is entitled when
T&H is administrating an external entity or government’s program will exempted from this
provision when required by such entity or government.
☐ Order the Respondent to complete community work services.
☐ Require the respondent to pay restitution to the petitioner and association persons in the form
of money, subsistence foods, or other appropriate reparations.
☐ Require the respondent’s attendance at dance practices, art classes or gatherings, language
classes or gatherings, or other cultural activities.
☐ Require the respondent’s participation in Peace Circles.
☐ Order other relief the court determines necessary.
AFFIDAVIT
I have been a victim of domestic violence, family violence, dating violence, stalking, or/and
sexual assault by the respondent as described below. (Include dates of incident, places it
occurred, injuries suffered, weapons used, and if children were involved. List the most recent
incident first. Attach additional sheets if necessary.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Petition for Protective Order Tlingit & Haida Tribal Court
Page 8 of 8 320 W. Willoughby Ave. Ste 300
Juneau, AK 99801
Phone: 907-463-7165
Fax: 866.532.3558
I, __________________________, swear or affirm under penalty of perjury that all the
information I provide in this petition and affidavit is true to the best of my knowledge and belief.
________________________ ______________________________
Date Petitioner’s Signature
______________________________
Print Name
Subscribed and sworn to or affirmed before me at ______________, __________ on _________.
City State Date
_________________________________________
Clerk of the Court, Notary Public or Other Person
(SEAL) Authorized to administer Oaths
My commission expires: __________________
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Completed 18 November 2021

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