Fillable Sample Petition For Order Of Protection (Administrative Office of the Courts)

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Sample Petition For Order Of Protection (Administrative Office of the Courts)

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Rev. September 2020

IN THE CIRCUIT COURT OF __________________COUNTY, ARKANSAS

___________ DIVISION

__________________________________________

PETITIONER’S/AFFIANT’S HOME ADDRESS (STREET)

__________________________________________

CITY STATE ZIP CODE

__________________________________________

PETITIONER’S/AFFIANT’S PLACE OF WORK (NAME)

__________________________________________

________________________________________

PETITIONER’S/AFFIANT’S FIRST NAME; LAST NAME

________________________________________

AGE DATE OF BIRTH

________________________________________

DRIVER’S LICENSE NUMBER

________________________________________

TELEPHONE NUMBER

________________________________________

EMAIL ADDRESS

STREET ADDRESS OF PLACE OF WORK

__________________________________________

CITY STATE ZIP CODE

VS.

NO. DR________________________________

__________________________________________

RESPONDENT’S HOME ADDRESS (STREET)

__________________________________________

CITY STATE ZIP CODE

__________________________________________

RESPONDENT’S PLACE OF WORK (NAME)

__________________________________________

________________________________________

RESPONDENT’S FIRST NAME; LAST NAME

________________________________________

AGE DATE OF BIRTH

________________________________________

DRIVER’S LICENSE NUM

BER

_______________________________________

TELEPHONE NUMBER

_______________________________________

EMAIL ADDRESS

STREET ADDRESS OF PLACE OF WORK

__________________________________________

CITY STATE ZIP CODE

PETITION AND AFFIDAVIT FOR AN ORDER OF PROTECTION

I, the Petitioner/Affiant, am asking the Court to issue an Order of Protection. A hearing will be set

within 30 days. At the hearing, I will present evidence for an Order of Protection, and the Respondent will have

an opportunity to appear and contest the Order of Protection. I state, under oath and subject to the penalty of

PERJURY, that the following facts are true and correct to the best of my knowledge and belief:

____Petitioner/Affiant elected to omit an address, but a mailing address has been provided to the court.

1. I am at least 18 years of age, or I am under 18 years of age, but emancipated. Respondent is

____at least 18 years of age or ____ under 18, but emancipated.

____I am an adult employee or volunteer of a domestic-violence shelter or program on behalf of a

minor, including a married minor.

I am filing this petition:

(a)____ on behalf of myself AND/OR

(b)____ on behalf of a family or household member who is

____A minor(s), Name(s):__________________________________________________

_______________________________________________________________________

____An adjudicated incompetent person, Name:________________________________

The

relationship between

Respondent

and me (or the

person(s)

on whose behalf

filing

this

petition

and affidavit is/are:

(

MARK

HAT

PLY.)

(A.)_____ We are spouses or _____ former spouses (Divorce date:___________________________)

(B.)_____ We are related by blood:

_____Respondent is the parent

_____Respondent is my child

_____Other BLOOD relationship: Respondent is my ______________________________.

(C.)____ We currently reside together or cohabit.

Date we started living together: Month___________/Year_________.

(D.)____ We formerly resided together or cohabited.

Dates we lived together: Month________/Year______ until Month_________/Year________.

(E.)____ We have or have had a child in common.

(F.)____ We are presently or in the past have been in a dating relationship.

Length of Relationship: Month_________/Year________ until Month_________/Year________.

3. I believe I am entitled to an Ex-Parte Temporary Order of Protection because I (or the person(s) on whose

behalf I am filing this petition and affidavit am (is/are) afraid of the respondent and there is an immediate and present

danger of domestic abuse.

(In the following section, describe the details of the MOST RECENT ACT to you or members of your

household that caused you to seek the Court’s assistance. DO NOT LIST PREVIOUS THREATS OR ACTS OF

ABUSE IN THIS SECTION.)

DATE OF MOST RECENT ACT: ______________________________________________________

(Include the day of the week)

LOCATION OF MOST RECENT ACT: _________________________________________________

Address

*****DO NOT WRITE BELOW THIS LINE OR ON BACK OF PAGES*****

THREATS OF PHYSICAL HARM: (STATE THE SPECIFIC THREATS)

_____________________________________________________________________________________

(If more space is needed, you may attach additional page(s) as page 3A, 3B, etc.)

*****DO NOT WRITE BELOW THIS LINE OR ON BACK OF PAGES*****

ACTUAL PHYSICAL ABUSE OR HARM: (DESCRIBE THE PHYSICAL ACTS)

_____________________________________________________________________________________

(If more space is needed, you may attach ad

ditional page(s), as page 4A, 4B, etc)

*****DO

OT WRI

BELOW

NE OR

ACK

PAGES****

OR The Respondent is scheduled to be released from incarceration within thirty (30) days and upon the

respondent’s release there will be an immediate and present danger of domestic abuse to me.

Place of incarceration: _________________________________________________________________________

Date of release: ______________________________________________________________________________

The reasons I believe I will be in danger when Respondent is released are: ______________________________

_____________________________________________________________________________________

6. The Respondent has previously been arrested for or convicted of acts of violence. _____ No.

______ Yes. If yes, give the following details:

WHEN: ______________________________ WHERE: ______________________________________

WHAT RESPONDENT DID: ____________________________________________________________

_____________________________________________________________________________________

*****DO NOT WRITE BELOW THIS LINE OR ON BACK OF PAGES*****

4. The above MOST RECENT ACT was reported to a law enforcement agency.

_____ No. __________ Yes, it was reported to: _

_____________________________________________________________________________________ Agency

Date ____________________________________________________________________________________

Action taken by the law enforcement agency.

5. Any additional acts of domestic violence by Respondent against me (or the person(s) on whose

behalf I am filing this petition and affidavit, including verbal threats, harassment and physical abuse, are: (DO

NOT INCLUDE THE ACTS LISTED IN ANY ABOVE SECTIONS)

■

7. The Respondent and I have the following minor children: (State their names, ages, and addresses, if

different from yours. DO NOT LIST YOUR CHILDREN UNLESS THEY ARE ALSO RESPONDENT’S

CHILDREN.

_____________________________________________________________________________________

NAME AGE ADDRESS

_____________________________________________________________________________________

NAME AGE ADDRESS

_____________________________________________________________________________________

NAME AGE ADDRESS

If there are minor children living in the residence in which you herein request that Respondent be

excluded from who

are yours or Respondent’s children, but not belonging to both of you, please list

them below:

Petitioner’s/Affiant’s children only: _______________________________________________________

Respondent’s children only: _____________________________________________________________

8. I, the Petitioner/Affiant’s ask the Court to issue an Ex-Parte Temporary Order of Protection with the

following provisions: (MARK

ALL THAT ARE APPLICABLE)

____ Excluding the Respondent from the shared residence of the parties or the residence of the

Petitioner/Affiant or Victim. Address of residence:

_____________________________________________________________________________________

Street Address City

Owner/Renter of residence: (MARK ONE)

Petitioner Respondent Both Neither

____ Excluding the Respondent from the place of business, employment, school or other location

of the Petitioner/Affiant or Victim, which is (are):

_____________________________________________________________________________________

Name of Business or employment

_____________________________________________________________________________________

Address of Business or employment City

_____________________________________________________________________________________

School

_____________________________________________________________________________________

Address of School City

*****DO NOT WRITE BELOW THIS LINE OR ON BACK OF PAGES*****

Other: Identify: _______________________________________________________________________

_____________________________________________________________________________________

Address City

____ Prohibiting the Respondent, directly or through an agent, from contacting the Petitioner/Affiant or victim,

except under the following conditions:___________________________________________________

_______________________________________________________________________________________

____ Prohibiting the Respondent from disconnecting the following phone numbers used by either the

Petitioner and/or the minor children: _________________________________________________________

____ Awarding Petitioner/Affiant temporary custody of the minor children listed in Paragraph 7.

____ Requiring Respondent to pay child support.

State the weekly take-home pay of Respondent: _________________________________________

____ Requiring Respondent to pay spousal support.

State the weekly take-home pay of Respondent: _________________________________________

____ Excluding Petitioner’s/Affiant’s address from the notice to the respondent.

____ Requiring Respondent to pay filing fees, service fees, court costs, and petitioner’s/affiant’s attorney’s fees

(if applicable.)

9. I, the Petitioner/Affiant, understand that if the Court determines that I am not entitled to an Ex-Parte

Temporary Order of Protection, a hearing will still be scheduled for an Order of Protection. I, the Petitioner,

request that after the hearing the Court issue an Order

of Protection based upon the same provisions I have

requested in Paragraph 8.

10. A Court Order ALREADY EXISTS concerning the custody of Respondent’s and my child(ren) listed in

Paragraph 7.

_____ No _____ Yes

IF YES, state the contents of the order, as follows:

______________________________COUNTY AND STATE WHERE ORDER WAS ISSUED

____________________________________________ WHO WAS AWARDED CUSTODY

_____________________________________________AMOUNT OF CHILD SUPPORT

11. The Respondent and I have been involved in the following cases in the Pulas

ki Circuit Court:

Type of case:

____ Domestic Abuse Date(s):________________________________

____ Divorce Date(s):________________________________

____ Paternity Date(s):________________________________

____ Child Support Date(s):________________________________

____ Other Date(s):________________________________

12. I, the Petitioner/Affiant, state under oath and subjec

t to the penalty of PERJURY that the above Petition

and Affidavit for an Order of Protection and following Notice contain facts which are true and correct to the

best of my knowledge and belief. I UNDERSTAND THAT IF I DO NOT RETURN TO THE SCHEDULED

HEARING, THE PETITION AND AFFIDAVIT FOR AN ORDER OF PROTECTION PROBABLY

WILL BE DISMISSED. I understand that if any of the above statements are later determined by the court to be

false, I may be assessed the costs of this action, including filing fees, Sheriff’s service fees, and the Respondent’s

attorney’s fees, if any.

DATE: _______________ PETITIONER’S/AFFIANT’S SIGNATURE:_______________________________

VERIFICATION

STATE OF ARKANSAS

COUNTY OF PULASKI

Subscribed and sworn to before me this _____ day of _______________________, 20________.

_______________________________________

NOTARY PUBLIC

My Commission expires:

______________________________

NOTICE

All persons filing a Petition for Order of Protection must provide as much

of the following information as possible:

Respondent/Defendant

First Middle Last

Employer:

CAUTION:  Respondent possesses a firearm

 Respondent has history of extreme

violence

Respondent Identifiers

Sex

Race

DOB

mm/dd/yyyy

Ht.

Wt.

Eyes

Hair

SS#, DL# or other ID#

Phone #

Email address

Distinguishing Characteristics:

Relationship Identifiers:  Current or former spouses  Parents of child(ren) in common

 Live together  Current or past dating relationship  Other Relative (Explain)

____________________________________________

Signature of Person providing information

Address:

_____________________________________

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Completed 27 January 2021

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