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 Former Spouse Dating, how long? ____________ Roommate
Boyfriend Former Boyfriend Intimate Partner Neighbor
Girlfriend Former Girlfriend Related by marriage
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.
___________________________________________________________________________
1) 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)
2) If Stalking Violence, do you believe that you are a victim of stalking because the Respondent has
willfully, maliciously, and repeatedly (check all that apply to you):
Followed Harassed Cyberstalked
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) Are you the Custodian of any minor (under 18 years of age) child or children? YES NO
If yes, please list their name, age and date of birth:
___________________________________________________ Date of birth: ________________
___________________________________________________ Date of birth: ________________
___________________________________________________ Date of birth: ________________
___________________________________________________ Date of birth: ________________
___________________________________________________ Date of birth: ________________
8) Is the Respondent the natural parent of any of the child or children listed above?
YES NO
If no, please circle the name of the child or children listed above who are not children of you and
the Respondent.
Please see the clerk once you have completed this form or should you have any questions.
