Fill and Sign the Colorado Protection Form

 Municipal Court  County Court  District Court  Denver Juvenile  Denver Probate _________________________________ County, Colorado Court Address: Petitioner: ___________________________________ Date of Birth: _______________________ v. Respondent: ___________________________________ Date of Birth: ________________________ COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E-mail: FAX Number: Atty. Reg. #: The address of the Protected Person may be omitted from the written order of the Court, including the Register of actions. Case Number: Division Courtroom VERIFIED  COMPLAINT  MOTION FOR CIVIL PROTECTION ORDER I, ____________________________________ (name of person) request this Court to issue a Civil Protection Order, and in support of this request state the following: 1. I am seeking this Civil Protection Order as a victim of the following: (Mark the applicable circumstances.)  Domestic Abuse (§13-14-101(2), C.R.S.)  Stalking (§18-3-602, C.R.S.)  Sexual Assault (§18-3-402(1), C.R.S.)  Unlawful Sexual Contact (§18-3-404, C.R.S.)  Abuse of the Elderly or an At-Risk Adult (§26-3.1-101(1) and (7), C.R.S.)  Physical Assault, Threat or other situation. 2. I reside or am employed in the County of _____________________, State of _________________, and _________________________________ (name of person) resides or is employed in the County of __________________, State of ________________. I know ______________________ (name of person) because: 3. The other Protected Persons are (list full name, date of birth, sex, and race): Full Name of Protected Person Date of Birth Sex Race Full Name of Protected Person Date of Birth Sex Race  I have completed and attached the form titled “Affidavit Regarding Children” JDF 404 as children are identified as Protected Persons above. JDF 402 R3/18 VERIFIED COMPLAINT/MOTION FOR CIVIL PROTECTION ORDER Page 1 of 4 (1) Court Copy (2) Petitioner Copy (3) Respondent Copy 4. a) The most recent incident that causes me to ask for a Civil Protection Order occurred on or about _____________________ (date), at about ________ (time), in _______________________ (County), when _____________________________ (name of person) did the following to me and/or the above named Protected Persons: Be specific: What was the threat or acts of violence? Where did this occur? Were the minor children or other Protected Persons present? Was a weapon involved? b) The most serious incident that causes me to ask for a Civil Protection Order occurred on or about ___________________________(date), at about ________(time), in _____________________ (County), when __________________________________ (name of person) did the following to me and/or the above named Protected Persons: Be specific: What was the threat or acts of violence? Where did this occur? Were the minor children or other Protected Persons present? Was a weapon involved? c) Any other past incidents of violence or threats? Be specific: What was the threat or acts of violence? Where did this occur? Were the minor children or other Protected Persons present? Was a weapon involved? d) Are you aware of any other Protection Orders currently in effect against you or the other person?  Yes  No If Yes, list any relevant information, such as the issuing Court, State, and date of the order: 5. I believe that I and/or the other Protected Persons named in this action are in imminent danger from __________________________________ (name of person):  Harm to my/our life or health if he/she is not restrained as requested.  Physical or emotional harm to my/our emotional health or welfare if he/she is not excluded from the family home or the home of another. 6.  I request that I be permitted to omit my address from this Verified Complaint/Motion for Civil Protection Order, because I fear that including my address will endanger me and/or the other Protected Persons. 7. I request the following relief from the Court that (name of person): JDF 402 R3/18 VERIFIED COMPLAINT/MOTION FOR CIVIL PROTECTION ORDER Page 2 of 4 (1) Court Copy (2) Petitioner Copy (3) Respondent Copy a)  Be ordered to refrain from contacting, harassing, injuring, stalking, touching, sexually assaulting, molesting, intimidating, and threatening me or other protected persons. b)  Be ordered to have no contact at all with me or the other Protected Persons. or  Be allowed only the following limited contact with me or the other Protected Persons: Be specific. c)  Be excluded from my home at (address): If you checked section 6, do not provide your address. ________________________________________________________________________________ d)  Be ordered to stay at least ________ yards from the following places. (address or description) If you checked section 6, do not provide your address.  Home: __________________________________________________________________________  Work: Name: _________________________ Address: _________________________________  School: Name: _________________________ Address: ___________________________________  Other: __________________________________________________________________________ e)  Be ordered to have no contact with the minor children and that I be awarded temporary care and control and Interim Decision-Making Responsibilities for the children. or  Be awarded temporary care and control of the children and that the other person be given Parenting Time with the children and Interim Decision-Making Responsibilities as follows: Be specific. f)  Be ordered to refrain from molesting, injuring, taking, transferring, encumbering, concealing, or disposing of or threatening harm to an animal owned, possessed, leased, kept or held by me or my minor child(ren), or other protected persons. Arrangements for possession and care are as follows: g)  Be ordered, if this is a domestic abuse protection order, to not possess and/or purchase a firearm, ammunition, or other weapon AND to relinquish any firearm or ammunition within the time ordered by the Court. h)  Be ordered to refrain from interfering with me or other protected persons at our place of employment or place of education and from engaging in conduct that impairs my or other protected person’s employment, educational relationships, or environment. i)  Other: JDF 402 R3/18 VERIFIED COMPLAINT/MOTION FOR CIVIL PROTECTION ORDER Page 3 of 4 (1) Court Copy (2) Petitioner Copy (3) Respondent Copy  I understand that once a Civil Protection Order is issued it cannot be modified or dismissed by me or the other person without permission of the Court.  By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form.  By checking this box, I am acknowledging that I have made a change to the original content of this form. VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the ______ day of ________________, _______, at ______________________________________ (date) (month) (year) (city or other location, and state OR country ___________________________________ ______________________________________ (Printed name of  Petitioner  Respondent) Signature of  Petitioner  Respondent ____________________________________ Attorney, if applicable Stop: If you checked box number 6, do not fill in your address and telephone number. ___________________________________________ Address ___________________________________________ ___________________________________________ Telephone Number Notice: Colorado Revised Statutes §13-14-105 identifies that a temporary injunction may be issued by the Court and that upon personal service or upon waiver and acceptance of service by the Restrained Person, is to be in effect against the Restrained Person for a period determined to be appropriate by the Court. This injunction restrains the Restrained Person from: 1. Ceasing to make payments for mortgage or rent, insurance, utilities or related services, transportation, medical care, or child care when the Restrained Person has a prior existing duty or legal obligation for making such payments. 2. Transferring, encumbering, concealing, or in any way disposing of personal effects or real property, except in the usual course of business or for the necessities of life. The Restrained Person shall be required to account to the Court for all extraordinary expenditures made after the injunction is in effect. Any injunction issued shall not exceed one year after the issuance of the Permanent Civil Protection Order. JDF 402 R3/18 VERIFIED COMPLAINT/MOTION FOR CIVIL PROTECTION ORDER Page 4 of 4 (1) Court Copy (2) Petitioner Copy (3) Respondent Copy