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KEN BURKE, PINELLAS COUNTY CLERK OF THE CIRCUIT (Pinellas County Clerk of the Circuit Court and Comptroller)

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CTCIV232 (REV. 06/2019) PAGE 1
KEN BURKE, PINELLAS COUNTY CLERK OF THE CIRCUIT COURT AND COMPTROLLER
Today’s Date: _______________ Case Number: ___________________
DATING VIOLENCE INFORMATION SHEET
Please read: This is an information sheet to assist the Clerk in preparing your Petition for Injunction for
Protection Against Dating Violence. You are the Petitioner; the individual against whom you are filing is
the Respondent. Please fill in all information below completely and to the best of your knowledge.
Please be advised that the penalties and fines for knowingly making false statements on a petition are as
follows:
Perjury (Making False Statements): A criminal offense; guilty of a misdemeanor of the 2
nd
Degree.
Penalties and Fines for Perjury:
F.S. 775.082(4) (b): For a Misdemeanor of the 2
nd
Degree, a definite term of imprisonment not
exceeding 60 days.
F.S. 775.083(1) (e): $500.00 fine.
NOTE: If the Respondent does not know your address, you may request a confidential filing of your
address. Write “Confidential” on the lines below where your contact information is requested.
Petitioner’s Name: _____________________________________________________________________
First Middle Last Suffix
Alias/ Former Name (if any): _____________________________________________________________
First Middle Last Suffix
Complete Address: _____________________________________________________________________
Street City State Zip Code
Telephone: _____________________________ Date Of Birth: ___________________________
Respondent’s Name: ___________________________________________________________________
First Middle Last Suffix
Alias/ Former Name (if any): _____________________________________________________________
First Middle Last Suffix
Complete Address: _____________________________________________________________________
Street City State Zip Code
Respondent’s Place of Employment: _______________________________________________________
Place of Employment Address: ___________________________________________________________
Street City State Zip Code
Date of Birth: ___________________________
Is the Respondent Incarcerated? YES NO If Yes, Where: _______________________
CTCIV139 (REV. 06/2019) PAGE 2
Is either party a member of the armed forces (active, reserve or guard)? YES NO
If yes, indicate which party is a member of the armed forces: Petitioner Respondent
1) Is the person you are seeking protection from your:
Spouse or Former Spouse or Boyfriend
Related by Marriage or Blood Relation or Girlfriend
If question 1 does not apply, please state how you have come into contact with the person
you are requesting an Injunction for Protection (Restraining Order) against.
___________________________________________________________________________
2) Have you ever lived together or do you now share the same single family dwelling unit with the
person you are requesting the Restraining Order against?
YES (have lived together) NO (never lived together)
3) Are you now, or have you ever been involved in any court action with the
defendant/respondent?
Yes No
If yes, please explain briefly: _______________________________________________________
4) Are you aware of any Restraining Orders now in effect against the defendant/respondent?
YES NO
5) The last episode of abuse took place: Date:___________________________________
6) Do you genuinely fear being hurt by the respondent? YES NO
7) (a) Were the petitioner and respondent involved in a continuing and significant relationship of a
romantic or intimate nature? YES NO
(b) Were the petitioner and respondent more than casual acquaintances?
YES NO
(c) Did the relationship between the petitioner and respondent extend beyond mere ordinary
interaction in a social or business setting? YES NO
(d) Have the petitioner and respondent been involved in a dating relationship within the past six
months? YES NO
(e) Was the relationship between the petitioner and respondent characterized by the
expectation of affection or sexual involvement between the parties?
YES NO
(f) Were the petitioner and respondent involved in a relationship that occurred over a period of
time and on a continuous basis? YES NO
Please see the clerk once you have completed this form or should you have any questions.
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KEN BURKE, PINELLAS COUNTY CLERK OF THE CIRCUIT (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 10 February 2021

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