Petition For Domestic Violence Civil Protection Order {DV10.01-D}

FORM 10.01-D: PETITION FoR DOMESTIC vroLENcE crvrL pRorEcr]oN ORDER COURT iN THE cour{TY, oHt3 Petitioner Address City, State, Zip Code Date of Birth Case No. Judge/Magistrate v. PETITION FOR DOMESTIC VIOLENGE CIVIL PROTECTTON ORDER (R.C. 31 13.31) Respondent Address City, State, Zip Code Date of Birth CHECK EVERY tr THAT APP DO NOT WRITE YOUR ADDRESS ON THIS FORM. PLEASE PROVIDE ANOTHER MAILING ADDRESS WHERE YOU CAN SAFELY RECEIVE NOTICES FROM THE COURT, THIS FORM IS A PUBLTC RECORD. tr t. Petitioner is a family or household member of Respondent and a victim of domestic violence and seeks relief on Petitioner's own behalf. The relationship of Petitioner to Respondent is that of: 'I CnitO of Respondent I Spouse of Respondent I Former spouse of Respondent E Parent of Respondent tr Natural parent of Respondent's child I Foster Parent I Other relative (by blood or marriage) of f RespondenV Petitioner who has lived with Respondent at any time Person "living as a spouse of Respondent" is defined as: now cohabiting; r or cohabited within five years before the alleged act of domestic violence . Petitioner seeks relief on behalf of the fol DATE OF BIRTH PETITIONER HOW RELATED TO RESPONDENT I Amended: March 1,2014 FORM 1O.O1.D: PETITION FOR DOMESTIC VIOLENCE CIVIL PROTECTIoN oRDER Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Page 2 of4 Form 10.01-D] 3. r\EsPer ruerrr rras engageo ln Ine Isllowlng Respondent has engaged rn the fcllowing act(s) of domestic viclence (Describr (Describe the acts as {ully as possible. Case No.. Attach additlr:na! oages if necessary.) 4' Petitioner requests that the Court grant relief under R.C. 31 13.31 to protect the petitioner and/or the family or household members named in this Petition from domestic ,iol"nce bt grr.ti"g a civil protection E (a) order that: Directs Respondent to not abuse Petitioner and the family or household members named in this Petition by harming, attempting to harm,.threatening, following, stalking, harassing, forcing sexual relations upon them, or by committing sexually oriente-d offensjJ against them. tr (b) Requires Respondent to leave and not return to or interfere with the following residence and grants Petitioner exclusive possession of the residence: I (c) Divides household and family personal property and directs Respondent to not remove, damage, hide, or dispose of any property or funds that petitioner owns or possesses. tr (d) Temporarily allocates parental rights and responsibilities for the care of the following minor children and suspends Respondent's visitation rights until a full hearing is held (include names and birth dates of the minor children): tr (e) Establishes be supervised or occur under such conditions that the Court determines will ensure the safety of temporary visitation rights with the following minor children and requires visitation to Petitioner and the minor children (include names and birth dates of the minor children): Amended: March 1,2014 FORM 10.01-D: PETITION FOR DOMESTTC VTOLENCE CtVtL PROTECTTON ORDER Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Page 3 of 4 Form 10.01-DI tr(0R'equiresRespondenttoprovidefinancialsupportfor.Petitioner3lli'xlm.o members nameci in this peritron. fI tgl I (h) D (i) Requires Respondent to compiete batrerer counseling, substance abuse counseling, or other counseling as determined necessary by the Court. Requires Respondent to refrain from entering, approaching, or contacting (by any means) the residence, school, business, and place of employment of or approaching or ionticting (by any means) Petitioner and the family or household members named in this petition. Requires Respondent to permit Petitioner or other family or household member to have exclusive use of the following motor vehicle: lncludes the following additional provisions: n 0) Is 6' 7. 8' Petitioner further requests that the Court issue an ex parte(emergency) protection order under R.C. 3113.31(D) and (E) and this petition. Petitioner further requests that the Court issue no mutual protection orders or other orders against Petitioner unless atl of the conditions of R.C. 31 13.31(EX4) are met. Petitioner further requests that if Petitioner has a victim advocate, the Court permit the victim advocate to accompany Petitioner at all stages of these proceedings as required Oy R.C. 31 i 3.31(M). fai. Petitioner further requests that the Court grant such other relief as the Court considers equitable and TYPE OF CASE also subject me to criminal penalties for perjury under R.C. 2921.i1. I hereby swear or affirm that the answens above are true, complete, and accurate to the best of my knowledge. I understand that falsification of this document may result in a contempt of court finOing against me which could result in a jail sentence and fine, and that fatsification of this document mayDO NOT SIGN THIS FORM UNLESS YOU ARE tN FRONT OF THE PERSON WHO WILL NOTARIZE THE PETITON FOR YOU. SIGNATURE OF PETITIONER Sworn to and subscribed before me on this day of NOTARY PUBLIC FORM 10.01.0: PETITION FOR DOMESTIC VIOLENCE clvlL Amended: March 1,2014 Discard all previous versions of this form PROTECTTON ORDER American LegalNet, Inc. www.FormsWorkFlow.com [Page 4 of 4 Form 10.01-DI Case No iF YOU ARE REQUESTING YOUR ADDRESS R ON THIS FORM. PLEASE PRoVIDE ANCTHER MAILING ADDRESS WHERE YOU CAN SAFE-Y RECEIVE NOTICES FROM THE COURT. THIS FORM IS A PUBL]C RECORD. Petitioner's Safe Address: Signature of Attorney for Petitioner (if applicable) Name of Attorney (if applicabte) Attorney's Address City, State, Zip Code Attorney's Registration Number Attorney's Telephone Attorney's Fax Attorney's Email Amended: March 1,2014 Discard all previous versions of this form FORM 10.01-D: PETITION FOR DOMESTIC VTOLENCE CtvtL PROTECTION ORDER American LegalNet, Inc. www.FormsWorkFlow.com [Page 4 of Form 10.01D] The folicrrving local servioe ag=ncies provide legal assistance andicr suppcrt services fcr vicrrms of dcmesiic vrol:r:: Legal AiC 211-9440 Dcmestic Relations (Civil Protection Crders) OA'7 a1/1-i (J(J / -UJ+' Butier Countir lVientai Health 896-7887 Community Counseling and Crisis Center 523-4146 Middletown Health Center 424-2466 Ohio Victims of Crime Compensation Program 1 -800-824-8263 Prosecuting Attorney 887-3437 Resolutions Domestic Violence Program 867-2804 or 867-2653 i Family Service of Butier County 868-3245 or 867-7574 Children's Diagnost