CTCIV139 (REV. 03/17) PAGE 2
1) Is the person you are seeking protection from your:
Spouse or Former Spouse or Boyfriend
Related by Marriage or Blood Relation or Girlfriend
2) 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.
______________________________________________________________________________
3) 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)
4) Are you now, or have you ever been involved in any court action with the
defendant/respondent?
Yes No
If yes, please explain briefly:_______________________________________________________
5) Are you aware of any Restraining Orders now in effect against the defendant/respondent?
YES NO
6) The last episode of abuse took place: Date:___________________________________
7) Do you genuinely fear being hurt by the respondent? YES NO
8) Is there an eyewitness to, or direct evidence or affidavits from eyewitnesses of, the facts that
form the basis upon which relief is sought?
YES NO
9) (a) Was the petitioner a victim of any one incident of sexual battery? YES NO
(b) Was the petitioner a victim of or exposed to a lewd or lascivious act committed upon or in
the presence of a person younger than 16 years of age?
YES NO
(c) Was the respondent luring or enticing a child? YES NO
(d) Was there any sexual performance by a child, or any other forcible felony wherein a sexual
act was committed or attempted, regardless of whether criminal charges based on the
incident were filed, reduced, or dismissed by the state attorney?
YES NO
10) Did the petitioner report the sexual violence to a law enforcement agency, and is the petitioner
cooperating in any criminal proceedings against the respondent, regardless of whether criminal
charges based on the sexual violence were filed, reduced, or dismissed by the state attorney?
YES NO
11) Was the respondent who committed the sexual violence against the victim or minor child
sentenced to a term of imprisonment in state prison for sexual violence and the respondent’s
term of imprisonment has expired or is due to expire within 90 days of today?
If yes, what is the respondent’s release date? _________________ YES NO
Please see the clerk once you have completed this form or should you have any questions.
