Petition And Affidavit For A Protection Order Domestic Abuse {UJS-091A}

Form UJS-091A (Domestic Petition) Rev. 1 STATE OF SOUTH DAKOTA ) IN CIRCUIT COURT ) COUNTY OF ) JUDICIAL CIRCUIT Petitioner TPO NO. -vs- PETITION AND AFFIDAVIT FOR A PROTECTION ORDER Respondent (DOMESTIC ABUSE) I, , the above-named Petitioner, or the Parent/Guardian of the minor child Petitioner (the Filer), being duly sworn upon oath, state and affirm the following: At least one party to the protection order227Petitioner, Respondent (the person against whom I seek this Protection Order), or a Protected Party (a minor child in my custody also victimized by Respondent)227is a resident of South Dakota. Petitioner resides in County, (state); Respondent resides in County, (state); and any Protected Parties not residing with Petitioner or Respondent, reside in County, (state). Please check this box if there is a custody order in another state regarding the children of Petitioner and Respondent. Please attach a copy of the custody order to this Petition. The person I am asking the Court to restrain from committing acts of domestic abuse (the Respondent) is, in relation to the Petitioner and any Protected Parties: (check all that apply): a spouse (married); ; ; a I AM ASKING THE COURT FOR A PROTECTION ORDER BASED UPON THE FACTS BELOW: On or about (month) (day) , (year) , at approximately o222clock (am/pm), Respondent committed the following act(s) of domestic abuse against Petitioner (if not me, my minor child who is related to Respondent) and any Protected Parties (other minor child in my custody related to Respondent): (check all that apply): Respondent caused physical harm or bodily injury. Respondent attempted to cause physical harm or bodily injury. Respondent222s actions inflicted fear in Petitioner and/or any Protected Parties that Respondent was about to cause physical harm or bodily injury to said Petitioner or Protected Party. Respondent violated a protection order. American LegalNet, Inc. www.FormsWorkFlow.com Form UJS-091A (Domestic Petition) Rev. 2 Respondent willfully, maliciously, and repeatedly followed Petitioner and/or any Protected Parties. Respondent pursued a knowing and willful course of conduct which seriously alarmed, annoyed, or harassed Petitioner and/or any Protected Parties with no legitimate purpose. The pattern of conduct was a series of acts over a period of time, however short, showing a continuing pattern of harassment. Respondent made a credible threat with intent to cause Petitioner and/or any Protected Parties reasonable fear of death or great bodily injury. The person willfully, maliciously, and repeatedly harassed Petitioner and/or any Protected Parties by means of any verbal, electronic, digital media, mechanical, telegraphic, or written communication. Respondent committed a crime of violence against Petitioner or any Protected Parties. Provide a detailed description of what happened on the above date: Yes No Don222t Know Was law enforcement called? Yes No Don222t Know Was Respondent arrested for this incident? Yes No Don222t Know Is Respondent in jail? Yes No Don222t Know Has Respondent violated previous protection orders? If so, against whom Give the date of the violation and the county and state of the violation Yes No Don222t Know Has Respondent been found guilty of violating previous protection orders? If so, against whom Give the date of the conviction and the county and state of the conviction Yes No Don222t Know Does Respondent possess guns or weapons? Yes No Don222t Know Was a weapon used in this incident? Yes No Don222t Know Has Respondent threatened anyone with a weapon? Provide a detailed description of other similar incidents or actions that Respondent has committed and reasons you believe it will continue: American LegalNet, Inc. www.FormsWorkFlow.com Form UJS-091A (Domestic Petition) Rev. 3 Continued from Page 2 REQUEST FOR HEARING AND PROTECTION ORDER Based upon this Petition and Affidavit in which I truthfully set forth the details of the domestic abuse, I respectfully ask the Court to set a date to hear this matter and after hearing the evidence, to grant Petitioner and any Protected Parties a Protection Order: 1)To Restrain Respondent from acts of abuse and physical harm, making threats of abuse, stalking or harassment. 2)To Grant the Protection Order for a period of time (no longer than 5 years). 3)To exclude Respondent from Petitioner222s residence listed in 4C. 4)To Order that Respondent shall not come within a distance of from the following persons and places: A. The Petitioner personally B. The following minor children named as other Protected Parties: More names attached Name Date of birth Relationship C. Petitioner222s residence (street/apt) (city), (state) . (zip) - D. Petitioner222s place of employment (street) (city), (state) (zip) - E. Other places (street/apt) (city) , (state) (zip) - (street/apt) (city) , (state) (zip) - (street/apt) (city) , (state) (zip) - 5)To award me temporary custody of our minor child(ren), whose names are 6) To establish temporary visitation for espondent with the minor child(ren) named aboveconsisting of: Existing order in File # Supervised at Jurisdiction: South Dakota South Dakota tribe Other State Other Other Visitation: American LegalNet, Inc. www.FormsWorkFlow.com Form UJS-091A (Domestic Petition) Rev. 4 7)To Order that Respondent shall pay temporary (If you are requesting support, you must provide proof of the monthly income of both parties at the hearing.): child support in the amount of $ a month starting on and continuing until further order of the Court; Child support shall be paid to: Kneip Building 700 Governors Drive Pierre, SD 57501 spousal support in the amount of $ a month starting on and continuing until further order of the Court. Spousal support shall be paid to the Clerk of Courts Office in the county this order was filed. 8)To Order Respondent receive parenting classes approved or provided by the Department of Social Services, SDCL 25-10-5. 9)To Order Respondent to obtain counseling as follows: 10)That Respondent be restrained from contact with the Petitioner and any Protected Parties, by any direct or indirect means except as authorized by a court order. 11)To Order other relief which I believe is necessary for Petitioner222s protection and any Protected Parties222 protection, as follows: (If you are requesting an immediate temporary protection order without notice to Respondent and without an opportunity for Respondent to appear, you must state why you believe Petitioner or any Protected Parties will suffer immediate and irreparable injury or damage if you or they have to wait until the hearing.) REQUEST FOR IMMEDIATE PROTECTION ORDER WITHOUT NOTICE TO THE OTHER PARTY I am not requesting an immediate Temporary Protection Order. In addition to what I have requested in sections 1-10 above, I further request that the Court grant Petitioner and any Protected Parties an immediate Temporary Protection Order restraining Respondent from committing acts of domestic abuse based upon the following sworn statements and beliefs: The reasons Petitioner and any Protected Parties need this order immediately and cannot wait until the scheduled hearing are: I believe that Petitioner, and/or any Protected Parties will suffer immediate and irreparable injury, loss or damage if not granted an immediate Temporary Protection Order without notifying Respondent and his/her attorney or giving Respondent an opportunity to be heard. American LegalNet, Inc. www.FormsWorkFlow.com Form UJS-091A (Domestic Petition) Rev. 5 The immediate and irreparable injury, loss or damage that I believe will be suffered is: On this day of , , I swear or affirm under oath that the information I have provided in this Petition and Affidavit are true and correct to the best of my knowledge. I believe Petitioner and any Protected Parties are entitled to the protection I have requested. I am asking for this protection for valid reasons and am not attempting to harass the person I am seeking protection against and am not attempting to abuse or delay the court process or any other legal action. Your Signature as Filer Only / Petitioner (check one) Signed and sworn to before me on