INSTRUCTIONS FOR COMPLETING "PETITION FOR PERSONAL PROTECTION ORDER"
Please print neatly.
By lling in this form, you are asking for a personal protection order that tells the respondent not to do certain things
you don't want him or her to do. If you are in immediate danger, you should ask the judge for an "ex parte" order,
which can be issued without waiting for a hearing.
Items A through I must be completed before your petition can be
led with the court. Please read the instructions for
each item. Then ll in the correct information for that item on the form.
A
Write your name, address, and telephone number in the "Petitioner" box. If you are under 18 years of age, write
in your age. Write the name, address, telephone number, and date of birth or age of the person you want
restrained in the “Respondent” box. If you want your address and telephone number to be kept from the
other party, do not write your address here. Put in the address of a relative or friend or a post ofce box
where the court can contact you.
B
Check the boxes that best describe your relationship with the respondent.
C
Check the box if the respondent is required to carry a rearm while at work. If you aren't sure, check the box
"unknown."
D
Check whether there is a pending case between you and the respondent. Examples of a case are: divorce,
separate maintenance, support, paternity, child support, other personal protection actions, etc. If there is a
pending case, ll in the case number, the name of the court, the county, and the state or province where the
action was led, and the name of the judge.
Check whether there are any court orders or judgments between you and the respondent. Examples of orders
are divorce judgments, parenting time (visitation) orders, custody orders, other personal protection orders, etc.
If there are other court orders or judgments, ll in the case number, the name of the court, the county, and the
state or province where the order or judgment was entered, and the name of the judge that signed the order.
E
Explain in as much detail as possible why you are asking for a personal protection order. Describe what has
happened or what has been threatened so the judge has enough facts to decide if a personal protection order
should be signed. Include dates and places. Write on a separate sheet of paper and attach it to this form.
F
Check only those boxes you need because you must be able to convince the judge you need all the protection
you are requesting. On the lines after each item you check, ll in the requested information such as names,
addresses, or specic types of activity you do not want allowed. Check item "5.b" only if you want to keep the
other party from entering onto property other than your home (for example, school, work, etc.). Check item "5.e"
only if there have been two or more acts of harassment. If you want the court to order that any records that exist
which contain information about yourself or your minor children be kept condential, state that in box "5.l."
Examples of such records are school reports that the respondent would normally have access to.
G
An "ex parte order" means you do not have to let the respondent know in advance that you are asking the court
for an order and you do not have to wait for a court hearing to get the order. Check the box for an "ex parte
order" if you believe the other party might hurt you or threaten you if he or she found out you were getting a
personal protection order.
If you do not need to check the "ex parte" box, you must have a court hearing.
H
If you are under 18 years old, you may need an adult (called a "next friend") to petition for you. Check this box
if you have a next friend helping you le this form, and have the next friend sign the petition.
I
Write in today's date and sign the form. Hand the form to the court clerk. The clerk will fill in the rest of the
information and will give you your copies.
