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PROTECTION ORDER INSTRUCTIONS DURING SHUTDOWN 1. Complete all (18th Judicial District Court of Kansas)

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PROTECTION ORDER INSTRUCTIONS DURING SHUTDOWN
1. Complete all forms.
2. For assistance with completing the Protection Order forms, help is available
Monday through Friday, from 9:00 a.m. to 4:00 p.m. Please call:
For further assistance completing your forms you may email your forms
to protectionorder@dc18.org or fax to 316-941-5365
3. When the forms are completed, send the entire packet (including this sheet)
to the Protection office by: SCAN and EMAIL to
protectionorder@dc18.org; or FAX - 316-941-5365;
Stepstone: 316-833-0760
Wichita Area Sexual Assault Center: 316-361-1177
Wichita Family Crisis Center: 316-351-3623
Protection Order Liaison hot-line: 316-660-5290
Catholic Charities Harbor House: 316-263-6000
4. Fill out the following information below and the clerk will return your copies to you.
This information WILL NOT be filed with the court file.
Name:
Phone number:
Email:
Fax:
Address:
City, state, zip:
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Rev. 7/2019 KSJC
Page 1 of 3
GENERAL INSTRUCTIONS
FOR THOSE ASKING FOR A PROTECTION FROM ABUSE ORDER
NOTICE
The protection from abuse process is designed to provide quick and immediate
protection. However, the process may require time, expertise, or more than one hearing. If
you have questions, you should ask for help from an attorney or victim services advocate.
The Kansas Crisis Hotline (1-888-363-2287) or Kansas Legal Services (1-800-723-6953) may
be able to help you find an attorney or advocate.
These are basic forms and they do not cover every situation. The Clerk of the
District Court cannot help you with these forms. The clerk cannot give legal advice to you
or tell you about your rights or responsibilities. The clerk can only provide very limited
information about the protection order process. You can find more information about
protection from abuse at
http://www.kcsdv.org/resources/brochures/criminal-justice/pfa.html; and
https://www.kansaslegalservices.org/node/2036/pfa-tips-tricks-part-1-preparing-your-pfapfs.
1. You may ask for a protection from abuse order:
a. For yourself; or,
b. For yourself and a minor child(ren); or,
c. For only a minor child(ren).
You may file on behalf of a minor child if:
a. You are the child’s parent; or
b. You are an adult residing with the child; or
c. You are the child’s court-appointed legal custodian or guardian.
2. Each person for whom protection is sought must be in (or have been in) an “intimate
partner or household member” relationship with the defendant.
“Intimate partner or household member” relationship means:
a. Persons who are in a dating relationship (a social relationship of a romantic
nature); or,
b. Persons who have been in a dating relationship; or,
c. Persons who live together; or,
d. Persons who have lived together; or,
e. Persons who have had a child in common.
Rev. 7/2019 KSJC
Page 2 of 3
3. Each person needing protection must have been abused. This means that one of the
following must have occurred:
a. The defendant physically hurt you or a minor child on purpose; or,
b. The defendant tried to physically hurt you or a minor child; or,
c. The defendant threatened to physically hurt you or a minor child; or,
d. The defendant engaged in any sexual contact or attempted sexual contact with you
or a minor child when such person was incapable of giving consent; or,
e. The defendant engaged in sexual conduct (touching or sexual intercourse) with a
minor child under 16 years of age.
4. If you meet the requirements above, you may file a Petition for Protection from Abuse
Order with any district court. If you want your address and telephone number to remain
confidential, you must complete the Protection from Abuse Confidential Address
Form and include it with your petition.
5. You must notify the defendant by personal service that you have filed a Petition for a
Protection from Abuse Order. To obtain personal service, you must fill out a Request
for Service form, asking that the sheriff deliver the Petition for Protection from Abuse
Order to the defendant.
6. If the defendant is a minor, you must complete the Minor Defendant Addendum.
Petitions, motions and temporary protection from abuse orders filed against a minor
defendant must be served by serving the minor and:
a. The minor’s guardian or conservator, if any; or,
b. The minor's father or mother; or,
c. A person having the minor's care or control; or,
d. A person with whom the minor resides.
If service cannot be made upon any of these people, then service may be obtained as
provided by order of the judge.
7. You should be available to testify at future hearings as set by the judge. If you fail to
appear, the case may be dismissed. You are the one asking for the protective order, and
you must convince your judge of what you claimed to be true. You may bring other
evidence and call additional witnesses in support of your claim.
8. Your final protection order will expire after one year or on the date stated in the order
unless you ask for an extension from the court before the order expires.
Extension for one year
To ask for a one-year extension, you can use the form titled “Motion to Extend Final
Protection from Abuse Order for One Additional Year.” You must file the motion
with the clerk of the district court and mail a copy of the motion to the defendant. You
Rev. 7/2019 KSJC
Page 3 of 3
must file your motion to extend the order before your order ends. It is a good idea to file
the motion at least a month before your order ends because this process can take several
weeks.
Extension for two or more years
If the defendant has violated a protection order or been convicted of a person felony
against you or a member of your household, you may ask the court to extend the
protection order for two years or longer. You can use the form titled “Motion to Extend
Final Protection from Abuse Order for Two Additional Years or Up to Life.” The
motion asking to extend an order for two years or longer must be filed with the clerk of
the district court and then personally served on the defendant. The court must hold a
hearing where the defendant may appear, present evidence, and question witnesses. You
must file your motion to extend the order before your order ends. It is a good idea to file
the motion at least a month before your order ends because this process can take several
weeks.
9. If you are the defendant and you want to ask for a protection from abuse order against the
plaintiff, you must meet all the requirements in paragraphs one (1) through three (3)
above, and then you may file a written counter-petition.
10. Child Support
If you decide to ask the court to order or modify child support, it is highly recommended
that you get the advice of an attorney. In order for the court to order or modify child
support, you must complete a Domestic Relations Affidavit and a Child Support
Worksheet and attach them to the Petition for Protection from Abuse. If the court
grants child support, the court will complete the Child Support Addendum and attach it to
the Final Protection from Abuse Order. You will then need to complete a Kansas
Payment Center Form, attach it to a copy of the Final Protection from Abuse Order
including the Child Support Addendum and provide it to the Clerk of the District Court.
11. Wireless Telephone Number(s)
You may ask the court to transfer the rights to and the billing responsibility for the
wireless telephone numbers used by you and/or the children in your care from the
defendant to you. If the court grants your request, the court will complete an Order
Transferring Wireless Telephone Number(s). You must send a copy of the file-
stamped Order Transferring Wireless Telephone Number(s) and the Confidential
Information for Order Transferring Wireless Telephone Number(s) to the wireless
service provider’s agent for service of process listed with the secretary of state.
07/01/2012
IN THE DISTRICT COURT OF ______________ COUNTY, KANSAS
____________________, Plaintiff
vs. Case No. _______________
____________________, Defendant
PROTECTION FROM ABUSE CONFIDENTIAL ADDRESS FORM
(K.S.A. 60-3104(e))
NOTE: IF THE COURT FINDS THAT THE PLAINTIFF’S ADDRESS AND TELEPHONE
NUMBER NEED TO REMAIN CONFIDENTIAL FOR THE PROTECTION OF THE PLAINTIFF
OR THE MINOR CHILD(REN), THIS FORM WILL BE SHOWN ONLY TO AUTHORIZED
COURT OR LAW ENFORCEMENT PERSONNEL AND WILL NOT BE DISCLOSED TO THE
PUBLIC OR TO THE DEFENDANT. IT IS THE PLAINTIFF’S RESPONSIBILITY TO NOTIFY
THE COURT OF ANY CHANGE IN ADDRESS OR TELEPHONE NUMBER.
Name of Plaintiff:
Confidential Address:
Street
City ________________________ State Zip Code
Phone Number ________________________________
SERVICE COVER SHEET AND NCIC INFORMATION FORM
Rev. 7/2017 KSJC
THIS FORM IS NOT TO BE INCLUDED IN THE PUBLIC RECORD AND SHOULD BE
DESTROYED ONCE THE REQUIRED INFORMATION IS ENTERED IN THE NCIC FILE.
This information is intended to be used by law enforcement to identify the defendant for
enforcement of the order and for entry into the National Crime Information Center (NCIC)
database. Please fill out the information as completely and correctly as possible, be particularly
careful with the dates of birth and spelling of names. PLEASE PRINT.
If there is more than one person being protected by the order (i.e. children), use the second page
to provide information about each protected person.
Restrained Person/Defendant’s Name:
Any other name(s) Defendant has been known by:
____________________________________________
____________________________________________
Defendant can be found at (give all available addresses):
Home Address: ________________________________
___________________________________________
___________________________________________
Phone number(s): ____________________________
Times Defendant is usually there_________________
__________________________________________
Place of employment: __________________________
___________________________________________
___________________________________________
Phone number(s): ____________________________
Times Defendant is usually there_________________
__________________________________________
Other Address: ________________________________
___________________________________________
___________________________________________
Phone number(s): ____________________________
Times Defendant is usually there_________________
___________________________________________
Restrained Person/Defendant Identifiers: (Please include all
available information.)
SEX
RACE
HT
WT
HAIR
EYES
SOCIAL SECURITY NUMBER
DRIVERS LICENSE #
DL STATE
DL EXP. DATE
VEHICLE MAKE
VEHICLE MODEL
VEHICLE YEAR
Distinguishing Features (tattoos, scars, locations frequented, etc.):
Please describe: ___________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Does Defendant wear glasses? Yes No
Does Defendant own or possess any weapons? Yes No
If so, what kind(s)? ________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
Protected Person’s Name:
Relationship to Defendant:
are or
have been in a dating relationship
reside together or formerly resided together
have a child in common
Protected Person’s Identifiers:
Full Date of Birth (mm/dd/yyyy)
(It is important to include the protected person’s full date of birth)
Sex: Female Male
Race __________________
SERVICE COVER SHEET AND NCIC INFORMATION FORM
Other Protected Persons Information
Rev. 7/2017 KSJC
Protected Person’s Name:
Relationship to Defendant:
are or
have been in a dating relationship
reside together or formerly resided together
have a child in common
Protected Person’s Identifiers:
Full Date of Birth (mm/dd/yyyy)
(It is important to include the protected person’s full date of birth)
Sex: Female Male
Race __________________
Protected Person’s Name:
Relationship to Defendant:
are or
have been in a dating relationship
reside together or formerly resided together
have a child in common
Protected Person’s Identifiers:
Full Date of Birth (mm/dd/yyyy)
(It is important to include the protected person’s full date of birth)
Sex: Female Male
Race __________________
Protected Person’s Name:
Relationship to Defendant:
are or
have been in a dating relationship
reside together or formerly resided together
have a child in common
Protected Person’s Identifiers:
Full Date of Birth (mm/dd/yyyy)
(It is important to include the protected person’s full date of birth)
Sex: Female Male
Race __________________
Protected Person’s Name:
Relationship to Defendant:
are or
have been in a dating relationship
reside together or formerly resided together
have a child in common
Protected Person’s Identifiers:
Full Date of Birth (mm/dd/yyyy)
(It is important to include the protected person’s full date of birth)
Sex: Female Male
Race __________________
Protected Person’s Name:
Relationship to Defendant:
are or
have been in a dating relationship
reside together or formerly resided together
have a child in common
Protected Person’s Identifiers:
Full Date of Birth (mm/dd/yyyy)
(It is important to include the protected person’s full date of birth)
Sex: Female Male
Race __________________
01-24-13 CASE #________________________
SEDGWICK COUNTY SHERIFF’S OFFICE
PROTECTIVE ORDER WORKSHEET
Please supply all requested information and any other information that will assist deputies with serving the defendant. Please attach a
recent photograph if available. Supplying false information may result in criminal prosecution and civil penalties.
No attempt at service will be made without an address for the Defendant.
PLAINTIFF INFORMATION
Name: _____________________________________________________________Date of Birth:___________________
Race: ____ Sex: ________ Social Security Number: _______________________________
Driver’s License No. __________________________ State of Issue ________
Daytime Phone: ____________________________ Cell Phone: ___________________________
Home Address: __________________________________________________________________________
City: ___________________________ State: ________ Zip Code: ____________________________
DEFENDANT INFORMATION
Name: _______________________________________________________________ Date of Birth: _________________
Race: ____ Sex: ________ Social Security Number: __________________________________
Age: _________ Height: _______ Weight: ________ Hair: ________ Eyes: ___________
Tattoos/Scars or other Identifiers: ________________________________________________________________________
Driver’s License No. __________________________ State of Issue ________
Place of Birth: _____________________________
Daytime Phone: _________________ Cell Phone: ____________________ Work Phone:__________________
Home Address: ____________________________________________________________________________
City: ___________________________ State: ________ Zip Code: _______
Vehicle Description: ___________________________________________________________________________________
BEST ADDRESS FOR SERVICE DURING BUSINESS HOURS (8-5): _____________________________________________
WORK/SCHOOL/OTHER LOCATION FOR SERVICE:
Name of Business/School/Other Location: ______________________________________________________________________
Address: __________________________________________ Days There: Su M Tu W Th F Sa Time: __________________
(Please Circle)
Work Phone: ___________________________________
****FOR OFFICE USE ONLY****
RMS __________________ Circle One: PFA PFS
_________
BEAT AREA: _________
1
st
Attempt at SERVICE:
__________________________________________________________________________________________________
2
nd
Attempt at SERVICE:
__________________________________________________________________________________________________
3
rd
Attempt at SERVICE:
___________________________________________________________________________________________________
DEPUTY’S NOTES:
Rev. 7/2019 KSJC
Page 1 of 7
IN THE DISTRICT COURT OF COUNTY, KANSAS
Plaintiff Case No.
vs.
Defendant
Petition Pursuant to K.S.A. Chapter 60
PETITION FOR PROTECTION FROM ABUSE ORDER
(K.S.A. 60-3101 et seq.)
1. Plaintiff seeks an order for protection from abuse:
(check and fill out either a, b, or c)
a. For Plaintiff Only
(Kansas law requires a former or current relationship which may be established
by any one of the following options.)
Plaintiff and Defendant:
are in a dating relationship
were formerly in a dating relationship
reside together in the same residence
formerly resided together in the same residence
have a child in common
OR
b. For Plaintiff and minor child(ren)
Plaintiff is:
the parent of the child(ren)
an adult who resides with the child(ren)
the child(ren)’s court appointed legal custodian
the child(ren)’s court-appointed legal guardian.
Rev. 7/2019 KSJC
Page 2 of 7
(Kansas law requires a former or current relationship which may be established
by any one of the following options.)
Plaintiff and Defendant:
are in a dating relationship
were formerly in a dating relationship
reside together in the same residence
formerly resided together in the same residence
have a child in common
The minor child(ren) and Defendant:
reside together in the same residence
formerly resided together in the same residence
Plaintiff asks for protection for the following minor child(ren):
(give full names and year of birth)
NAME YOB PARENT’S NAME PARENT’S NAME
OR
c. Only for the minor child(ren)
Plaintiff is:
the parent of the child(ren)
an adult who resides with the child(ren)
the child(ren)’s court appointed legal custodian
the child(ren)’s court-appointed legal guardian.
(Kansas law requires a former or current relationship which may be established
by any one of the following options.)
Minor child(ren) and Defendant:
are in a dating relationship
were formerly in a dating relationship
reside together in the same residence
formerly resided together in the same residence
have a child in common
Rev. 7/2019 KSJC
Page 3 of 7
Plaintiff asks for protection for the following minor child(ren):
(give full names and year of birth)
NAME YOB PARENT’S NAME PARENT’S NAME
2. Defendant can be served at: (please provide all available addresses)
HOME: street city
state zip code phone number
times when defendant is usually there
WORK: street city
state zip code phone number
times when defendant is usually there
OTHER: street city _____
state zip code phone number
times when defendant is usually there
3. If the defendant is a minor, a Minor Defendant Addendum is attached.
4. Plaintiff needs a protection from abuse because Defendant: (check all that apply)
caused Plaintiff bodily injury or attempted to cause Plaintiff bodily injury
placed Plaintiff in fear of imminent bodily injury by threatening Plaintiff
caused the minor child(ren) bodily injury or attempted to cause the minor
child(ren) bodily injury
placed the minor child(ren) in fear of imminent bodily injury
engaged in any sexual contact or attempted sexual contact with the Plaintiff
without consent or when the Plaintiff was incapable of giving consent.
engaged in any sexual contact or attempted sexual contact with the minor
child(ren) without consent or when the minor child(ren) was incapable of giving
consent.
engaged in any of the following acts with a minor under 16 years of age who is
not the spouse of Defendant: sexual intercourse or lewd fondling or touching on
the person of either the minor or Defendant.
Rev. 7/2019 KSJC
Page 4 of 7
5. Describe why you are asking for a protection from abuse order and include specific
facts:
(Attach more pages as needed.)
6. Plaintiff requests that Plaintiff’s address and/or telephone number remain
confidential for the following reason(s): (complete if applicable)
(If Plaintiff requests that Plaintiff’s address remain confidential, Plaintiff must complete
the Protection from Abuse Confidential Address Form and include it with this petition.)
7. Plaintiff requests that the court issue an ex parte Temporary Order of Protection and Final
Order of Protection restraining defendant from:
abusing, molesting or interfering with the privacy or rights of the protected
person(s)
entering or coming on or around the premises or the residence of the protected
person(s) located at: ,
and the workplace located at: ___.
(Give address or other description of residence and workplace from which Defendant
is to be excluded. DO NOT include the residential address if Plaintiff is requesting
that Plaintiff’s residential address is to remain confidential.)
Rev. 7/2019 KSJC
Page 5 of 7
8. Plaintiff states the residence is:
jointly owned or rented and jointly occupied by Plaintiff and Defendant
owned or rented by Plaintiff
owned or rented by Defendant only
owned or rented by someone else (explain)
not applicable because Plaintiff and Defendant do not live together.
Plaintiff requests the court order that the defendant immediately move from and
not return to the residence, and that law enforcement officers be directed to remove
Defendant from the residence, located at:
9. Plaintiff requests that the court issue an ex parte order of temporary custody of the minor
child(ren) and has attached a completed UCCJEA form.
a. Defendant’s parentage of the following child(ren) has NOT been established and
Defendant has no right to custody or parenting time with the following child(ren):
b.
Defendant’s parentage of the following child(ren) has been established and the
Plaintiff
requests the following custody and parenting time orders concerning the
following child(ren):
Plaintiff requests the following orders:
i. Temporary legal custody (decision-making) and residency of the minor
child(ren) be:
Joint legal custody (decision-making) between Plaintiff and
Defendant until this order expires.
OR
Sole legal custody (decision-making) granted to Plaintiff
Defendant until this order expires.
ii. Rights of temporary parenting time as follows:
Defendant shall have no parenting time.
Rev. 7/2019 KSJC
Page 6 of 7
OR
Defendant shall have supervised parenting time as follows:
.
OR
Plaintiff and Defendant shall have parenting time as described in
the attached parenting plan.
iii. Plaintiff and Defendant shall exchange the minor child(ren) for
parenting time at:
.
10. The court should give copies of orders to the appropriate law enforcement agencies; set a
date, time and hearing on this matter; and issue summons to Defendant notifying
Defendant of this action and the relief requested.
11. After a hearing, the court should issue a Final Order of Protection from Abuse prohibiting
Defendant from committing any acts of abuse against the protected person(s), and order
the following additional relief: (check all that apply)
suitable alternate housing for Plaintiff and minor child(ren)
custody of the minor child(ren) (UCCJEA form completed)
child support
support of spouse
possession of personal property, and the assistance of law enforcement
officers in securing that property, if necessary
attorney’s fees, if represented by counsel, and costs
counseling for Defendant
the transfer of the rights to and billing responsibility for the wireless telephone
number of Plaintiff and/or minor child(ren) in the care of Plaintiff
other, please specify:
12. The following legal actions have been filed between Plaintiff and Defendant or involving
the minor child(ren): (check case type, give county filed in, and give case number and
date filed, if known)
Rev. 7/2019 KSJC
Page 7 of 7
divorce/custody
parentage
child in need of care
action seeking protective order
other
VERIFICATION
I verify under penalty of perjury under the laws of the state of Kansas that the foregoing
is true and correct. Executed on , 20 .
Plaintiff’s Signature
Plaintiff’s Name:
Address 1:
Address 2:
City, State, Zip:
Telephone Number:
(DO NOT include the residential address or telephone number if Plaintiff is requesting that
Plaintiff’s residential address and telephone number are to remain confidential. If Plaintiff
requests that Plaintiff’s address and telephone number remain confidential, Plaintiff must
complete the Protection from Abuse Confidential Address Form and include it with this
petition.)
Attorney representing Plaintiff (if any)
Attorney’s Name:
Address 1:
Address 2:
City, State, Zip:
Telephone:
Email: ______________________________________________
Email:____________________________________
CIVIL COVER SHEET
The civil cover sheet neither replaces nor supplements the filing and service of pleadings or other papers as required
by law. This form is required for use by the Clerk of the District Court for the purposes of initiating the civil docket
sheet. This information will not be available to the public and this document will be stored in a separate location from
the case file and then destroyed within a reasonable time. A new case will not be accepted without a cover sheet
attached. (THIS FORM MUST BE TYPED OR PRINTED LEGIBLY). This form can be found at www.kscourts.org.
NATURE OF SUIT (Click or mark in one circle only – If the case involves more than one of the following categories, indicate the
category having the highest dollar value)
CIVIL If a CH. 61: $______________ (Judgment Demand Amount)
TORT CONTRACT REAL PROPERTY STATE TAX
Asbestos Product Liability  Buyer Plaintiff  Eminent Domain WARRANT
Automobile Tort  Employment Dispute - Discrimination  Mortgage Foreclosure
Intentional Tort  Employment Dispute - Other  Other Real Property
Legal Malpractice  Fraud
Medical Malpractice  Landlord/Tenant - Unlawful Detainer MISCELLANEOUS
 Other Professional Malpractice  Landlord/Tenant Dispute – Other  60-1507
 Premises Liability  Seller Plaintiff (debt collection)  Habeas Corpus
 Slander/Libel/Defamation  Other Contract  Other Writs
Tobacco Product Liability
 Toxic/Other Product Liability CIVIL APPEALS OTHER CIVIL
 Other Tort  Administrative Agency
 Other Civil Appeal SMALL CLAIMS
DOMESTIC
MARRIAGE DISSOLUTION/DIVORCE PROTECTION FROM ABUSE PROTECTION FROM STALKING UIFSA
OTHER DOMESTIC RELATIONS NON-DIVORCE SUPPORT, CUSTODY OR VISITATION PATERNITY
PROBATE/ESTATE
GUARDIAN /CONSERVATOR DETERMINATION OF DESCENT ELDER ABUSE ADOPTION
Conservatorship/Trusteeship
Guardianship – Adult SEXUALLY VIOLENT PREDATOR OTHER PROBATE / ESTATE
Guardianship - Minor
Guardian/Conservator – Adult DECEDENT ESTATE CARE AND TREATMENT
Guardian/Conservator - Minor
JURY DEMAND YES (Check yes only if jury demand is included in petition or as a separate pleading) NO
SUMMONS ATTACHED: YES NO
SERVICE BY: PROCESS SERVER/ATTORNEY SHERIFF IN STATE ____________ SHERIFF OUT OF STATE _____________
County
State
SHERIFF’S PROCESS FEE ATTACHED YES NO
PLAINTIFF / SUBJECT INFORMATION DEFENDANT / OTHER PARTY INFORMATION
(ATTACH ADDITIONAL SHEET, IF NECESSARY) (ATTACH ADDITIONAL SHEET, IF NECESSARY)
NAME: NAME:
ADDRESS: ADDRESS:
PHONE: SEX: PHONE: SEX:
SSN: DOB: SSN: DOB:
DL OR STATE ID NO:__________________________ DL OR STATE ID NO:_ _________________________
State and Number State and Number
ALIAS NAMES USED:__________________________ ALIAS NAMES USED:
__________________________________________
ATTORNEYS ATTORNEYS (if known)
(Firm Name, Address, Telephone Number and Supreme Court ID Number) (Firm Name, Address, Telephone Number and Supreme Court ID Number)
FOR DOMESTIC CASES - NAME, DATE OF BIRTH AND SOCIAL SECURITY NUMBER OF EACH DEPENDENT CHILD:
(Name) (Date of Birth) (Social Security Number)
The requirement that Social Security numbers be included on domestic cases is mandatory, and authorized by the Supreme Court
and federal law. On non-domestic cases, the Social Security number is not mandatory. The number is used for purposes of
identification and may be disclosed as permitted by law. This form is not considered to be a public record.
For Office Use Only
Rev. 07/2019 KSJC
Page 1 of 5
IN THE DISTRICT COURT OF COUNTY, KANSAS
Protection from Abuse (K.S.A. 60-3101 et seq.)
Temporary Order of Protection from Abuse
Judge or Division:
Case Number:
Court ORI Number:
Plaintiff:
Relationship to Defendant:
are or have been in a dating relationship
reside together
formerly resided together
have a child in common
Plaintiff is filing on behalf of a minor child
vs.
Plaintiff Identifiers:
Year of Birth
Sex:
(Date File Stamp)
Defendant:
Address
Defendant Identifiers:
SEX
RACE
YOB
HT
WT
HAIR
EYES
LAST 4 DIGITS OF SSN (IF KNOWN)
DRIVERS LICENSE #
DL STATE
DL EXP. DATE
Protected Person(s): (Only the party, or parties, initialed by the judge are Protected Person(s).)
Plaintiff, (name of plaintiff)
The following child(ren):
Child’s Name
Child’s
Year of Birth
This order and its terms are directed at and apply to Defendant only.
THIS TEMPORARY ORDER SHALL REMAIN IN EFFECT UNTIL
SERVICE OF THE FINAL ORDER OR UNTIL TERMINATED BY ORDER
OF THE COURT.
ONLY THE COURT CAN CHANGE THIS ORDER.
Rev. 07/2019 KSJC
Page 2 of 5
The Court Finds: (Only the provision(s) initialed by the judge apply.)
Plaintiff filed a written verified petition on , 20 requesting a Temporary Order of
Protection from Abuse.
Plaintiff has shown the statutorily required relationship between Plaintiff and minor child(ren).
This court has jurisdiction over Plaintiff, Defendant and subject matter.
This court has child custody jurisdiction because it is home state, there is no home state and
Kansas has significant connections with the child(ren), temporary emergency jurisdiction,
other:
Plaintiff has established good cause for the court to issue a temporary order of protection from abuse.
A hearing has been set for , 20 , at : a.m. p.m., at
(Court) and summons has been issued.
The plaintiff’s address and telephone number shall remain confidential for the protection of the
Protected Person(s).
Order
The Court Orders:
Defendant shall not abuse, molest, or interfere with the privacy or rights of the Protected Person(s) wherever
they may be. [ NCIC 01 & 02 ]
Defendant shall not use, attempt to use, or threaten to use physical force, that would reasonably be expected to
cause bodily injury, against the Protected Person(s). [ NCIC 01 & 02 ]
Defendant shall not contact the Protected Person(s), either directly or indirectly, except as authorized by the
court in Paragraph 3(b) of this order. [ NCIC 04 & 05 ]
Defendant shall not direct or request another to contact the Protected Person(s), either directly or indirectly,
except as authorized by the court in Paragraph 3(b) of this order. [ NCIC 04 & 05 ]
Defendant shall not enter or come on or around the premises, the residence or workplace where the Protected
Person(s) resides, stays or works. [ NCIC 04 ]
Law enforcement officers are directed to grant any assistance necessary to protect the Protected Person(s)
from abuse by Defendant, and to provide any other assistance necessary to enforce these orders, including the
order excluding Defendant from the Protected Person(s) place of residence, wherever it may be.
[ NCIC 08 ]
Rev. 07/2019 KSJC
Page 3 of 5
CERTIFICATE OF COMPLIANCE WITH THE VIOLENCE AGAINST WOMEN ACT (VAWA): This
Order meets all the requirements of the Violence Against Women Act, 18 U.S.C. § 2265. This Court has
jurisdiction of the parties and the subject matter; Defendant has been afforded notice and a timely opportunity to
be heard as provided by the laws of Kansas. This Order is enforceable in all 50 states, the District of Columbia,
all Indian tribal courts and all United States territories and shall be enforced as if it were an order of
that jurisdiction pursuant to 18 U.S.C. § 2265.
Additional terms of this order are set forth below. (Only the provision(s) initialed by the judge apply.)
Housing and Property:
1. The plaintiff is granted exclusive possession of the residence located at:
. [ NCIC 03]
If the plaintiff is granted exclusive possession of the residence, Defendant shall immediately move
from the residence and may take only personal clothing and effects until further order of the court.
Law enforcement officials are directed to remove Defendant from the residence, and to ensure that
Defendant does not enter or re-enter the premises or any other residence the plaintiff may occupy.
2. Defendant shall not cancel utilities to the residence. The terms of this paragraph expire 60 days from
this order’s date of entry. [ NCIC 08 ]
Parentage and Custody:
3. For this paragraph, the court shall initial subparagraph (a) OR subparagraph (b), but not both.
a. Defendant’s parentage of the child(ren) has not been established through a marriage of the
parties or pursuant to the Kansas Parentage Act, K.S.A. 23-2201 et seq., and Defendant has
no right to custody or parenting time with the following named child(ren):
b. Defendant’s parentage of the child(ren) has been established through the marriage of the
parties or pursuant to the Kansas Parentage Act, K.S.A. 23-2201 et seq., and the following
custody and parenting time orders are entered:
i. Temporary legal custody and residency of the following named minor child(ren):
[ NCIC 09 ]
shall be:
Joint legal custody between the plaintiff and defendant until this order
expires;
OR
Sole legal custody granted to Plaintiff Defendant until this order
expires. [ NCIC 06 ]
Rev. 07/2019 KSJC
Page 4 of 5
ii. Rights of temporary parenting time shall be as follows: [ NCIC 06 ]
Defendant shall have no parenting time;
Defendant shall have supervised parenting time as follows:
;
Plaintiff and Defendant shall have parenting time as follows:
iii. Plaintiff and Defendant shall exchange the minor child(ren) for parenting
time at:
4. Law Enforcement shall assist Plaintiff in obtaining physical custody of the minor child(ren).
SO ORDERED:
Date Judge of the District Court
WARNINGS TO DEFENDANT
This order is effective when signed by the judge. Law enforcement officials shall immediately enforce
this order.
Violation of this order may constitute: violation of a protective order as provided in K.S.A. 21-5924,
and amendments thereto; assault as provided in K.S.A. 21-5412(a), and amendments thereto; battery
as provided in K.S.A. 21-5413(a), and amendments thereto; and domestic battery as provided in
K.S.A. 21-5414, and amendments thereto, and may result in prosecution and conviction under Kansas
criminal statutes.
If possession of the residence is granted to the plaintiff, violation of this order by Defendant constitutes
criminal trespass pursuant to K.S.A. 21-5808(a)(1)(C), and amendments thereto, and may result in
prosecution and conviction under Kansas criminal statutes.
Violation of this order may also be punishable as contempt of this court.
If Defendant has a concealed carry license, that license is subject to revocation pursuant to K.S.A. 75-
7c07, and amendments thereto. After a defendant’s concealed carry license has been revoked,
continuing to carry a concealed weapon may constitute a violation of K.S.A. 21-6302, and amendments
thereto.
Violation of this order may subject Defendant to prosecution for such federal crimes, including but not
limited to: Interstate travel to commit domestic violence; Interstate stalking; and Interstate violation
of a protection order.
Notice of Extension of this Temporary Order
(Pursuant to K.S.A. 60-3106)
If a hearing on the petition for protection is continued, the court may extend this Temporary Order of Protection
from Abuse for additional periods of time as it deems necessary.
Rev. 07/2019 KSJC
Page 5 of 5
Notice of Default
(Pursuant to K.S.A. 60-255)
If you fail to appear at the hearing, a default order may be entered against you and this Temporary Order of
Protection from Abuse may turn into a Final Protection from Abuse without further notice to you.
07/01/2012
IN THE DISTRICT COURT OF SEDGWICK COUNTY, KANSAS
________________________________
Plaintiff
vs.
________________________________ Case No. _________________
Defendant
Defendant address: PERSONAL SERVICE ONLY
_____________________________________
_____________________________________
_____________________________________
SUMMONS AND NOTICE OF HEARING FOR PROTECTION ORDER
To the above-named defendant:
You are notified that the attached petition for protection was filed against you in this court and that the court
has entered the attached temporary orders, or has not entered temporary orders against you.
A hearing on this matter has been scheduled on:
Date: ________________, 20____
Time: __________ a.m. p.m.
Place: Sedgwick County Courthouse, 525 N Main, Wichita, KS 67203, 1
st
Floor Jury Room.
Children are not allowed in the courtroom during this docket.
If you do not attend the hearing, final orders may be issued against you. You may appear and cross-examine the
plaintiff’s witnesses and present evidence as to why the orders sought should not be granted. You may file an answer or
counter-petition but are not required to do so. You have the right to appear with or without an attorney.
Date: _____________________ _____________________________________________
Clerk of the District Court/Deputy
RETURN OF SERVICE OF SUMMONS
I certify under penalty of perjury that I have served this summons and notice of hearing:
By personally delivering on the ______ day of ___________________, 20____, at _____:_____ a.m. p.m.,
a copy of the summons and a copy of the petition and temporary orders (if any) to the above named defendant.
All done in _______________________________ County, Kansas.
I certify under penalty of perjury that I was not able to personally serve this summons and notice of hearing.
Date:_____________________ _____________________________________________
Sheriff/Deputy
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PROTECTION ORDER INSTRUCTIONS DURING SHUTDOWN 1. Complete all (18th Judicial District Court of Kansas)

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Completed 2 June 2022

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