Florida Injunction Form

PETITION FOR INJUNCTION FOR PROTECTION AGAINST REPEAT VIOLENCE

IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,

IN AND FOR COUNTY, FLORIDA

Case No.:

Division:

Petitioner,

and

Respondent,

I, , being sworn, certify that the following statements are true:

SECTION I. PETITIONER

(This section is about you. It must be completed.)

1. Petitioner currently lives at the following address:

Petitioner seeks an injunction for protection on behalf of a minor child.

Petitioner is the parent or legal guardian of , a minor child who is living at home.

2. Petitioner's attorney's name, address, and telephone number is:

SECTION II. RESPONDENT

(This section is about the person you want to be protected from. It must be completed.)

1. Respondent currently lives at the following address:

Respondent’s Driver’s License number is:

2. Petitioner has known Respondent since:

3. Respondent's last known place of employment:

Employment address:

Working hours:

4. Physical description of Respondent:

Race: Sex: Male Female Date of Birth:

Height: Weight: Eye Color: Hair Color:

Distinguishing marks and/or scars:

Vehicle: (make/model) Color: Tag Number:

5. Other names Respondent goes by (aliases or nicknames):

6. Respondent's attorney’s name, address, and telephone number is:

SECTION III. CASE HISTORY AND REASON FOR SEEKING PETITION

(This section must be completed.)

1. Has Petitioner ever received or tried to get an injunction for protection against domestic violence, repeat violence, dating violence, or sexual violence against Respondent in this or any other court?

Yes No

If yes, what happened in that case?

2. Has Respondent ever received or tried to get an injunction for protection against domestic violence, repeat violence, dating violence, or sexual violence against Petitioner in this or any other court?

Yes No

If yes, what happened in that case?

3. Describe any other court case that is either going on now or that happened in the past between Petitioner and Respondent.

4. Respondent has directed at least two incidents of violence against Petitioner or a member of Petitioner's immediate family.

On , at

Please indicate here if you are attaching additional pages to continue these facts.

5. Other prior incidents are described below:

On , at

Please indicate here if you are attaching additional pages to continue these facts.

6. Petitioner genuinely fears repeat violence by Respondent. Explain:

7. Additional Information

[Choose all that apply]

a. Respondent owns, has, and/or is known to have guns or other weapons.

Describe weapon(s):

b. This or prior acts of repeat violence have been previously reported to:

SECTION IV. INJUNCTION

(This section must be completed.)

1. Petitioner asks the Court to enter a TEMPORARY INJUNCTION for protection against repeat violence that will be in place from now until the scheduled hearing in this matter.

2. Petitioner asks the Court to enter, after a hearing has been held on this petition, a final judgment of injunction prohibiting Respondent from committing any acts of violence against Petitioner and:

a. prohibiting Respondent from going to or within 500 feet of any place Petitioner lives;

b. prohibiting Respondent from going to or within 500 feet of Petitioner’s place(s) of employment or the school that Petitioner attends; the address of Petitioner's place(s) of employment and/or school is:

c. prohibiting Respondent from contacting Petitioner by telephone, mail, by e-mail, in writing, through another person, or in any other manner;

d. ordering Respondent not to use or possess any guns or firearms;

e. prohibiting Respondent from going to or within 500 feet of the following place(s) Petitioner or Petitioner’s immediate family must go to often:

f. prohibiting Respondent from knowingly and intentionally going to or within 100 feet of Petitioner’s motor vehicle; and any other terms the Court deems necessary for the safety of Petitioner and Petitioner’s immediate family.

I UNDERSTAND THAT BY FILING THIS PETITION, I AM ASKING THE COURT TO HOLD A HEARING ON THIS PETITION, THAT BOTH THE RESPONDENT AND I WILL BE NOTIFIED OF THE HEARING, AND THAT I MUST APPEAR AT THE HEARING. I UNDERSTAND THAT IF EITHER RESPONDENT OR I FAIL TO APPEAR AT THE FINAL HEARING, WE WILL BE BOUND BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED AT THAT HEARING.

I UNDERSTAND THAT I AM SWEARING OR AFFIRMING UNDER OATH TO THE TRUTHFULNESS OF THE CLAIMS MADE IN THIS PETITION AND THAT THE PUNISHMENT FOR KNOWINGLY MAKING A FALSE STATEMENT INCLUDES FINES AND/OR IMPRISONMENT.

STATE OF FLORIDA

COUNTY OF

Sworn to or affirmed and signed before me on by

Personally known

Produced identification

Type of identification produced