Petition For Order For Protection And Request For Hearing (On Behalf Of Child) {PO-0101}

STATE OF INDIANA ) ) SS: COUNTY OF ___________ ) IN THE ______________ COURT_____ (____________DIVISION, ROOM ____) CASE NO. __________________________ ___________________________________________ Name of Minor Child, Petitioner ___________________________________________, By Child's Next Friend, (Your Name) vs. ___________________________________________, Respondent (Person to be Restrained) ) ) ) ) ) ) ) PETITION FOR AN ORDER FOR PROTECTION AND REQUEST FOR A HEARING--Filed on Behalf of a Child IMPORTANT: This is a public document and a copy of it will be placed in the Court's file. A copy may also be sent to the Respondent. (Check those which apply) 1. I am filing this Petition for a child. The child who needs protection is or has been a victim of domestic or family violence, a sex offense, or stalking, and I am that person's: ___ parent ___ guardian ___ other representative (describe:___________________________ _________________________________________________). What is the Respondent's relationship to the child who needs protection? a. The Respondent is a family or household member (check only the line which best applies): ___ the Respondent is, or used to be my spouse and the child lived with us; ___ the Respondent and I resided together in an intimate relationship and the child lived with us; ___ the Respondent is a parent of the child; ___ the Respondent is, or used to, date the child; ___ the Respondent is, or has been, engaged in a sexual relationship with the child; ___ the Respondent and the child who needs protection have a child in common; ___ the Respondent and the child are related by blood or adoption. The Respondent is the child's _________________________; ___ the Respondent and the child are, or used to be, related by marriage. The Respondent is the child's _________________________; ___ the Respondent is, or used to be, the child's guardian; ___ the Respondent is, or used to be, the child's custodian; ___ the Respondent is, or used to be, the child's foster parent; 1 TCM-PO-0101 Approved 07/02 Rev. by Ind. Office Ct. Serv. 07/17 American LegalNet, Inc. www.FormsWorkFlow.com 2. b. c. ___ the child who needs protection is a minor child of someone in one of the types of relationships described above. ___the Respondent has committed stalking against the child who needs protection. ___the Respondent has committed a sex offense against the child who needs protection. 3. 4. How old is the Respondent? ________ years old. Please list all cases (divorce, protection orders, paternity, guardianship, criminal, juvenile, civil) involving the Respondent, or the Child you have with the Respondent (attach additional sheets of paper if necessary): Case Name Case Number County & State __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ _____ Continued on Attachment 4a. 5. This case is filed in this county because: _____ a. the Respondent lives in this county. _____ b. the incident(s) of domestic or family violence, stalking, or the sex offense happened in this county. _____ c. the child who needs protection lives in this county. _____ d. the Petitioner lives in this county. 6. If you are not represented by an attorney, fill in your public mailing address: __________________________________________________________________ __________________________________________________________________ This address will not be kept secret, so you should use a mailing address that you feel comfortable having public. If the Court grants the order, you may be eligible to obtain a confidential address through the Attorney General's Address Confidentiality Program (ACP). Email the ACP at: confidential@atg.state.in.us to get information on how to participate in that program. The Respondent has committed the following act(s) of domestic or family violence, stalking, or a sex offense (check those which apply): ___ the Respondent attempted to cause physical harm to the child who needs protection; ___ the Respondent threatened to cause physical harm to the child who needs protection; ___ the Respondent did cause physical harm to the child who needs protection; ___ the Respondent placed the child who needs protection in fear of physical harm; ___ the Respondent caused the child who needs protection to involuntarily 2 TCM-PO-0101 Approved 07/02 Rev. by Ind. Office Ct. Serv. 07/17 American LegalNet, Inc. www.FormsWorkFlow.com 7. engage in sexual activity by force, threat of force, or duress; ___ the Respondent committed stalking against the child who needs protection; ___ the Respondent committed a sex offense against the child who needs protection. ___ the Respondent committed an act of animal cruelty by beating, torturing, mutilating, or killing a vertebrate animal without justification with an intent to threaten, intimidate, coerce, harass or terrorize a family or household member. 8. Describe what happened in each of the above incidents including the date(s), place(s) and witnesses to each incident (attach additional sheets of paper if necessary): Date of Incident #1: ______________ Place of Incident: __________________________________________________ Description of Incident: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ List the names of all of the people who were present during the incident. You must include your own name if you were present: __________________________________________________________________ __________________________________________________________________ Date of Incident #2: ______________ Place of Incident: __________________________________________________ Description of Incident: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ List the names of all of the people who were present during the incident. You must include your own name if you were present: __________________________________________________________________ __________________________________________________________________ Date of Incide