Fill and Sign the Fillable Online Nycourts Depose and State the Following Form

FCA §154-d; CPL §§530.12 (3),(3-a),(3-b) Family Court General Form 5b Criminal Form 3 (Local Criminal Court): 12/2013 County of _________________________________ Petitioner AFFIDAVIT IN SUPPORT OF -against- ISSUANCE OF FAMILY COURT TEMPORARY ORDER OF PROTECTION (By Individual Complainant/Petitioner) Respondent. Index/Docket # _______________________________________ State of New York ) ): ss: County of ) I, (petitioner's name) 1 ___________________________________, having been d uly sworn, depose and state the following under the penalties of perjury: 1. The Family Court, County, is not in session at the present time. 2. The following family offense was committed on (s pecify date): ________ by the above- named Respondent [Check box or boxes]: ” Disorderly conduct ” Menacing in the second or third degree ” Harassment in the first or second degree ” Reckless endangerment ” Assault in the second or third degree ” Aggravated harassment in the second degree ” Attempted assault in second or third degree ” Stalking ” Criminal mischief ” Sexual misconduct ” Forcible touching ” Sexual abuse in the second 2 or third degree ” Strangulation ” Criminal obstruction of breathing or circulation ” Identity theft in 1 st, 2 nd or 3 rd degree ” Grand larceny in 3 rd or 4 th degree ” Coercion in 2 nd degree [Penal Law §135.60 (1),(2),or (3) 3. The Respondent and I are related as follows: ” we are married ” we were married ” we have a child in common ” we are parent & child ” we are related by blood or marriage [specify how ]: ” we are in an intimate relationship (NOT casual s ocial or business acquaintances) 1 NOTE: If the Petitioner is a peace or police officer, representative of a duly authorized agency or other person designated by the Court to file a petition p ursuant to Family Court Act §822, Family Court Gene ral Form 5c/ Criminal Form 4 should be used instead of this form . 2 Where victim is incapable of consent for reason other than being under age 17 [Penal Law §130.60(1)]. Family Court General Form 5b/Crim 3 Page 2 [describe]: ” we were in an intimate relationship (NOT casual social or business acquaintances)[describe]: 4. [Check one]: ” I filed a petition under Article 8 of the Family C ourt Act in Family Court,__________County, on [specify date]:__________. ” I intend to file a petition in Family Court, Count y, on the next day the Court is in session. 5. The following constitutes good cause for issuing a temporary order of protection:[Brie fly describe family offense and any other facts and rea sons supporting the need to protect me, my child(re n) or other members of my family or household]: 6.a. The following criminal, matrimonial or Family Court cases have been filed involving the respondent and me: [Specify type of case, who filed it, the court in which it was filed, the approximate date filed and the present status, if known]: b. The following orders of protection or tempo rary orders of protection have been issued against the respondent or against me: [Specify type of case in which the order was issued, persons protected by the order, the court that. issued it, the approximate date issued and expiration date, if known]: 7. I understand that the Family Court order issued by this Court shall expire on the date indicated on the order, which shall be not more tha n four calendar days after its issuance, unless sooner vacated or modified by the Family Court. I underst and that the matter will be transferred to the Family Court and that I must appear in Family Court on or before the date indicated. I further understand that I have a right to seek a criminal prosecution of resp ondent in addition to, or instead of, proceeding in Family Court. WHEREFORE, for the reasons stated above, I am reque sting that my application for a Family Court temporary order of protection be granted and that the matter be transferred to the Family Court, ________________ County. False statements in this affidavit are punishable a s a class A misdemeanor, pursuant to Penal Law §210.45. Sworn to before me this day of ________________________ Petitioner __________________________ (JUDGE): (SUPERIOR OR DESK OFFICER, POLICE DEPARTMENT): (NOTARY PUBLIC): TO THE CLERK OF COURT: This affidavit, together with any temporary orde r of protection so issued, shall be transmitted forthwith to the Family Court; if th e affidavit and order are transmitted by facsimile or other electronic means, the original shall be forwarded i mmediately thereafter.