Fill and Sign the Full Text of Ampquotthe History and Antiquities of Bicester a Form

- 1 - TO : _____________ , R esp onden t a b ove-n am ed , a n d h is a tto rn ey , __ ___________ ___ ___________ _____________ ____________ _____________ ___ ___________ _____________ ____________. Y OU W IL L P L EA SE T A KE N OTIC E t h at a t a s e ssio n o f t h e a b ove n am ed c o urt, t o b e he ld b efo re T he H onora b le _ ____________,_ ________ ____ o f F am ily C ourt, i n t h e __ _____ ______ C en te r, R oo m _ ____________, _ ______ ______, M in neso ta , o n _ ____________, 20 _ _, a t _ _____ _______ _ .M ., o r a s s o on t h ere afte r a s c o unse l m ay b e h eard , P etitio ner w ill m ove th e c o urt f o r a n O rd er a s f o llo w s: G EN ER A L D EN IA L A ND D IS M IS SA L:1 1. Den yin g R esp onden t t h e r e lie f p ra y ed f o r i n h is M otio n o f _ ____.2 2. Dis m is sin g R esp onden t's m otio n d ate d _ ____________.C O NTEM PT1 3. Adju dgin g R esp onden t i n c o nte m pt o f c o urt f o r f a ilu re t o a b id e b y p ara g ra p h _______ ______ o f t h e J u dg m en t a n d D ecre e h ere in , c o ncern in g p ay m en t o f _ ____________ t o Petitio ner.2 4. In t h e a lte rn ativ e, d ir e ctin g t h at j u dgm en t b e e n te re d i n f a v or o f P etitio ner a n d ag ain st R esp onden t f o r t h e u npaid b ala n ce o f t h e _ _____ _______ a w ard ed p urs u an t t o p ara g ra p h _______ ______ o f t h e J u dg m en t a n d D ecre e h ere in , t o geth er w ith i n te re st a ccru ed t h ere o n, a t t h e le g al r a te .3 5. Adju dgin g R esp onden t i n c o nte m pt o f c o urt f o r f a ilu re t o a b id e b y p ara g ra p h _______ ______ o f t h e J u dg m en t a n d D ecre e h ere in c o n cern in g m ain te n an ce o f m ed ic al a n d ho sp ita liz atio n i n su ra n ce c o v era g e f o r t h e b en efit o f t h e m in or c h ild re n o f t h e p artie s.4 6. Dir e ctin g t h at j u dgm en t b e e n te re d i n f a v or o f P etitio ner a n d a g ain st R esp onden t i n the a m ount o f _ __________ __ f o r m ed ic al a n d h osp ita liz atio n i n su ra n ce p re m iu m s P etitio ner m ad e be cau se o f R esp onden t's f a il u re t o m ain ta in s a id i n su ra n ce.5 7. Adju dgin g R esp onden t i n c o nte m pt o f c o urt f o r f a ilu re t o a b id e b y p ara g ra p h - 2 - __ _____ ______ o f t h e J u dg m en t a n d D ecre e h ere in , d ate d _ ____________.6 8. In t h e a lte rn ativ e, d ir e ctin g t h at j u dgm en t b e e n te re d i n f a v or o f P etitio ner a n d ag ain st R esp onden t f o r u npaid c h ild s u pport, t o geth er w ith i n te re st a ccru ed t h ere o n, a t t h e l e g al r a te .7 9. Adju dgin g R esp onden t i n c o nte m pt o f c o urt f o r f a ilu re t o a b id e b y p ara g ra p h _______ ______ o f t h e J u dg m en t a n d D ecre e d ate d _ __ __________, c o ncern in g t u rn in g o ver t o Petitio ner h er p ers o nal p ro p erty .8 10 . Adju dgin g R esp onden t i n c o nte m pt o f c o urt f o r f a ilu re t o a b id e b y p ara g ra p h _______ ______ o f t h e J u dg m en t a n d D ecre e d ate d _ __ __________ c o ncern in g n onpay m en t o f ch ild s u pport.9 11 . Adju dgin g R esp onden t i n c o nte m pt o f c o urt f o r f a ilu re t o a b id e b y p ara g ra p h _______ ______ o f t h e J u dg m en t a n d D ecre e d ate d _ __ __________ c o ncern in g R esp onden t's fa ilu re t o p ro vid e h ealth i n su ra n ce f o r t h e b en efit o f t h e m in or c h ild re n o f t h e p artie s.C U ST O DY1 12 . Gra n tin g t o P etitio ner t h e t e m pora ry l e g al a n d p hysic al c u sto dy o f t h e m in or ch ild re n o f t h e p artie s, n am ely , t o -w it: _ ____________.2 13 . Gra n tin g t h e l e g al a n d p hysic al c u sto dy o f t h e m in or c h ild re n o f t h e p artie s t o Petitio ner o r R esp onden t a s t h e c o urt m ay d eem t o b e i n t h e b est i n te re sts o f t h e m in or c h ild re n .3 14 . Gra n tin g t o P etitio ner a n d R esp onden t t h e j o in t t e m pora ry l e g al a n d p hysic al cu sto dy o f t h e m in or c h ild re n o f t h e p artie s. 1 5 . Gra n tin g t o P etitio ner t e m pora ry l e g al a n d p hysic al c u sto dy o f t h e m in or c h ild re n o f th e p arti e s, s u bje ct t o r e aso n ab le v is ita tio n b y R esp onden t. V IS IT A TIO N1 16 . Gra n tin g t o R esp onden t t h e r ig ht o f r e aso nab le v is ita tio n w ith t h e m in or c h ild re n o f th e p arti e s.C O URT S E R V IC ES:1 17 . Dir e ctin g t h at t h e H en nep in C ounty D ep artm en t o f C ourt S erv ic es c o nduct a - 3 - cu sto dy m ed ia tio n o r, i n t h e a lte rn ativ e, a n i n vestig atio n t o a id t h e c o urt i n d ete rm in in g w hic h pare n t s h ould h av e t h e p erm an en t c are , c u sto dy a n d c o ntr o l o f t h e m in or c h ild re n o f t h e p artie s.2 18 . Dir e ctin g t h at t h e H en nep in C ounty D ep artm en t o f C ourt S erv ic es a ssis t t h e p artie s he re to i n s c h ed ulin g a n d s u p erv is in g v is ita tio n o f t h e m in or c h ild re n a n d p ro vid e c o unse lin g t o t h e pa rtie s.3 19 . Req uir in g a c o m ple te f in an cia l i n vestig atio n b y t h e H en nep in C ounty D ep artm en t o f Co urt S erv ic es o f R esp onden t a n d a n i n vestig atio n b y t h e D ep artm en t o f C ourt S erv ic es i n conju nctio n w ith t h e a p pro pria te a g en cy i n t h e c o unty o f r e sid en ce o f R esp onden t a n d h is p re se n t sp ouse p urs u an t t o M in neso ta S ta tu te S ectio n 5 18.1 7.4 20 . Ord erin g a c o m ple te c u sto dia l i n vestig atio n b y t h e H en nep in C ounty D ep artm en t o f Co urt S erv ic es, F am ily C ou rt D iv is io n, f o r t h e p urp ose o f i n vestig atin g t h e p artie s t o a id t h e c o urt i n dete rm in in g w hic h p are n t s h ould h av e t h e p erm an en t l e g al a n d p hysic al c u sto dy o f t h e m in or ch ild re n o f t h e p artie s.5 21 . In t h e a lte rn ativ e t o t h e a b ove, o rd erin g a n e v id en tia ry h earin g a n d p en din g s u ch hearin g, t h e c o urt s h ould o rd er t h e t e m pora ry c u sto dy o f t h e m in or c h ild re n b e i n P etitio ner.C H IL D S U PPO RT1 22 . Dir e ctin g t h at R esp onden t s h all p ay t o P etitio ner a r e aso nab le s u m o f m oney a s a n d fo r t e m pora ry c h ild s u pport.2 23 . Ord erin g R esp onden t t o p ay t o P etitio ner a s a n d f o r t e m pora ry s u pport o f t h e m in or ch ild re n s u ch r e aso nab le s u m s a s t h e c o urt m ay d eem j u st a n d e q uita b le .3 24 . Dir e ctin g t h at a s a n d f o r c h ild s u pport R esp onden t i s t o p ay t h e m ortg ag e, i n te re st an d i n su ra n ce p ay m en ts m onth ly o n t h e h om este ad o f t h e p artie s.4 25 . Red ucin g t h e _ ____________ p er w eek c h ild s u pport p ay m en ts o rd ere d p urs u an t t o the O rd er d ate d _ ________ _ ___, b ecau se o f R esp onden t's i n ab ility t o m eet s a id r e q uir e d p ay m en ts .5 26 . Dir e ctin g t h at a n y s u pport p ay m en ts n ow i n a rre ars b e f o rg iv en b ecau se o f Re sp ond en t's i n ab ility t o p ay t h e c o urt- o rd ere d s u pport. - 4 - 6 27 . Restr a in in g P etitio ner f ro m g arn is h in g R esp onden t o r t a k in g o th er c o lle ctio n pro ced ure s t o c o lle ct o n t h e j u dgm en t o bta in ed b y P etitio ner f o r s u pport a rre ara g es.7 28 . Dir e ctin g t h at t h e J u dgm en t a n d D ecre e o f _ ____________ b e a m en ded t o r e q uir e an i n cre a se i n c h ild s u pport.8 29 . Dir e ctin g t h at t h e J u dgm en t a n d D ecre e h ere in b e a m en ded a t p ara g ra p h _______ ______ t o r e q uir e a ll f u tu re c h ild s u pport p ay m en ts t o b e p ay ab le t h ro ugh t h e H en nep in Co unty D ep artm en t o f C ourt S erv ic es.G UARD IA N A D L IT EM :1 30 . Dir e ctin g t h at a g uard ia n a d l ite m b e a p poin te d b y t h e c o urt t o r e p re se n t t h e i n te re sts of t h e m in or c h ild re n o f t h e p artie s.S P O USA L M AIN TEN ANCE:1 31 . Award in g t o P etitio ner a r e aso nab le s u m o f m oney a s a n d f o r t e m pora ry s p ousa l ma in te n an ce.2 32 . Award in g t o P etitio ner a r e aso nab le s u m o f m oney t o b e p aid b y R esp onden t a s a n d fo r t e m pora ry s p ousa l m ain te n an ce.3 33 . Dir e ctin g t h at t h e s ta tu s q uo c o ncern in g t e m pora ry s p ousa l m ain te n an ce b e ma in ta in ed , i .e ., _ ________ ____ p er m onth p ay ab le o n _ ____________.4 34 . Ord erin g R esp onden t t o p ay t o P etitio ner, a s a n d f o r t e m pora ry s p ousa l ma in te n an ce, s u ch r e aso nab le s u m s a s t h e c o urt m ay d eem j u st a n d e q uita b le .H OM EST EA D:1 35 . Award in g t o P etitio ner t h e t e m pora ry u se a n d p osse ssio n o f t h e h om este ad o f t h e pa rtie s.2 36 . Award in g t o P etitio ner t h e t e m pora ry a n d e x clu siv e u se a n d p osse ssio n o f t h e ho m este ad o f t h e p artie s l o ca te d a t _ ____________, a n d a ll o f t h e h ouse h old g oods, f u rn is h in gs a n d eq uip m en t a n d a ll o th er p ers o nal p ro perty s itu ate d t h ere o n a n d t h ere at.3 37 . Gra n tin g t o P etitio ner t h e t e m pora ry e x clu siv e u se a n d o ccu pan cy o f t h e h om este ad - 5 - of t h e p artie s l o cate d a t _ ___ _________, a n d t h e t e m pora ry , e x clu siv e u se a n d p osse ssio n o f t h e ho use h o ld g oods, f u rn is h in gs, a n d e q uip m en t l o cate d i n a n d a b out t h e h om este ad .P E R SO NAL P R O PE R TY :1 38 . Award in g t o P etitio ner t h e t e m pora ry u se a n d p osse ssio n o f t h e _ ____________ au to m ob ile w hic h s h e i s p re se n tly d riv in g.2 39 . Award in g t o P etitio ner t h e t e m pora ry u se a n d p osse ssio n o f t h e _ ____________ au to m ob ile , t it le t o w hic h i s i n t h e n am e o f t h e R esp onden t.3 40 . Award in g t o P etitio ner t h e t e m pora ry p o sse ssio n o f t h e c h ild re n 's p ers o nal c lo th in g an d e ffe cts , i n clu din g f u rn itu re a n d t o ys.4 41 . Award in g t o P etitio ner t h e u se a n d p osse ssio n o f t h e h ouse h old g oods o f t h e p artie s an d r e str a in in g R esp onden t f ro m r e m ovin g a n y o f t h ese i te m s f ro m t h e p osse ssio n o f P etitio ner.5 42 . Award in g t o P etitio ner t h e t e m pora ry u se a n d p osse ssio n o f t h e _ ____________ au to m ob ile , h er c lo th in g a n d p ers o nal e ffe cts a n d a r e aso nab le p ortio n o f t h e o th er p ers o nal p ro perty to i n clu de, b ut n ot t o b e l im ite d t o , h ouse h old g oods, f u rn is h in gs a n d e q uip m en t t o e n ab le P etitio ner to f u rn is h a n a p artm en t.6 43 . Gra n tin g t o P etitio ner t h e t e m pora ry e x clu siv e u se a n d p osse ssio n o f t h e __ _____ ______ a u to m obile o f t h e p artie s, a n d r e q uir in g R esp onden t t o p ay t h e e n cu m bra n ce th ere o n.7 44 . Req uir in g R esp onden t t o p ro vid e v erif ic atio n t h at h e i s m ain ta in in g t h e s a v in gs b ond whic h w ere i n e x is te n ce a s o f t h e e n tr y o f t h e J u dgm en t a n d D ecre e h ere in , f o r t h e b en efit o f t h e min or c h ild re n o f t h e p artie s, p urs u an t t o t e rm _ ______ ______ o f s a id J u dgm en t a n d D ecre e.IN DEB TED NESS:1 45 . Req uir in g R esp onden t t o c o ntr ib ute a r e aso nab le s u m o f m oney t o p ay o n t h e j o in t an d s e v era l i n d eb te d ness o f t h e p artie s.2 46 . Req uir in g R esp onden t t o p ay a ll b ills a n d o blig atio ns i n cu rre d b y P etitio ner t o t h e da te o f t h e h earin g o n P etiti o ner's M otio n f o r T em pora ry R elie f. - 6 - 3 47 . Ord erin g R esp onden t t o a ssu m e a n d p ay , a n d h old P etitio ner h arm le ss f ro m , t h e ex is tin g i n deb te d ness o f t h e p artie s, i n clu din g a n y a rre ara g e i n m ortg ag e p ay m en ts o r u tilitie s f o r th e h om este ad .IN SU RA NCE:1 48 . Req uir in g R esp onden t t o m ain ta in i n f u ll f o rc e a n d e ffe ct, w ith out c h an ge o f am ounts o r b en efic ia rie s a n d /o r i n su re d s, a ll i n su ra n ce p re se n tly b ein g m ain ta in ed b y R esp onden t, in clu din g, b ut n ot l im ite d t o , a ll i n su ra n ce c o verin g a ll r e al a n d p ers o nal p ro perty , a ll a u to m obile s, an d a ll l if e , m ed ic al a n d h osp ita liz atio n i n su ra n ce.L IQ UID A TIO N O R C O NTR O L O F A SSE TS:1 49 . Award in g t o P etitio ner t h e t e m pora ry c o ntr o l o f t h e _ ____________ w ith t h e au th ority t o s e ll t h e s a m e f o r i ts f a ir m ark et v alu e, u sin g t h e p ro ceed s t o m eet t h e n ecessa ry expen se s o f _ ____________ .2 50 . Award in g t o P etitio ner t e m pora ry p osse ssio n a n d c o ntr o l o f t h e m oneta ry a sse ts o f th e p arti e s, i n clu din g, b ut n o t l im ite d t o , s to ck s, s a v in gs a cco unts , c h eck in g a cco unts , s a v in gs ce rtif ic ate s, e tc .3 51 . Gra n tin g t h at P etitio ner m ay l iq uid ate t h e f o llo w in g i te m s f o r t h e p urp ose o f p ay in g 20 __ i n co m e t a x es i n t h e a p pro xim ate a m ount o f _ ____________: _ ____________.R EST R A IN IN G O RD ER :1 52 . Contin uin g i n f u ll f o rc e a n d e ffe ct d urin g t h e p en den cy o f t h is p ro ceed in g t h e ap plic ab le p ortio ns o f t h e R estr a in in g O rd er e n te re d o n _ ____________.2 53 . Dir e ctin g t h at R esp onden t s h all n ot h ara ss, m ole st o r i n a n y w ay i n te rfe re w ith Petitio ner.3 54 . Restr a in in g R esp onden t f ro m o bta in in g c re d it i n t h e n am e o f P etitio ner.4 55 . Restr a in in g a n d e n jo in in g e ach p arty ( 1 ) f ro m r e m ovin g a n y o f t h e h ouse h old g oods, fu rn is h in gs a n d e q uip m en t o r o th er p ers o nal p ro perty l o cate d i n o r a t t h e h om este ad ; ( b ) f ro m i n a n y way o r m an ner a b usin g, m ole stin g, i n te rfe rin g w ith o r d is p ara g in g t h e o th er p arty ; a n d ( c ) f ro m - 7 - se llin g, a ssig n in g, d is p osin g o f, c o ncealin g, p le d gin g, e n cu m berin g o r i n a n y o th er m an ner d iv estin g eith er p arty o f a n y o f t h e p artie s' a sse ts o f a n y n atu re , d urin g t h e p en den cy o f t h e a b ove p ro ceed in g and u ntil f u rth er O rd er o f t h e a b ove c o urt.A TTO RN EY 'S F E ES:1 56 . Award in g t o P etitio ner a r e aso nab le s u m o f m oney a s a n d f o r a tto rn ey 's f e es a n d co sts i n cu rre d i n r e sp ondin g t o R esp onden t's M otio n.2 57 . Dir e ctin g t h at t h e m atte r o f a tto rn ey 's f e es a n d c o sts b e r e se rv ed u ntil t r ia l o f t h is ma tte r.3 58 . Award in g t o P etitio ner a r e aso nab le s u m o f m oney t o b e a p plie d t o h er a tto rn ey 's fe es a n d c o sts t o e n ab le P eti tio ner t o m ain ta in t h is d is so lu tio n p ro ceed in g.4 59 . Award in g t o P etitio ner a r e aso nab le s u m o f m oney a s a n d f o r h er a tto rn ey 's f e es a n d co sts i n cu rre d i n b rin gin g t h is m otio n.A CCELER A TIN G O R A D VANCIN G F O R T R IA L1 60 . Dir e ctin g t h at t h e t r ia l o f t h is m atte r b e a ccele ra te d t o t h e f ir s t a v aila b le d ate .2 61 . Advan cin g t h e a b ove-c ap tio ned p ro ceed in g f o r t h e e arlie st p ra ctic al t r ia l d ate , f o r a n afte rn oon c erta in .M ODIF IC A TIO N O F O RD ER :1 62 . Dir e ctin g t h at t e rm _ ____________ o f t h e C ourt's O rd er f o r T em pora ry R elie f d ate d __ _____ ______ b e m odif ie d t o d ele te t h e p ro vis io ns t h at: _ ____________F A IL U RE T O P R O VID E A N SW ER S T O I N TER RO GATO RIE S:1 63 . Dir e ctin g t h at t h e A nsw er a n d C ounte r-P etitio n o f R esp onden t t h ere in b e s tr ic k en fro m t h e c o urt r e co rd a n d t h at P etitio ner b e a llo w ed t o p ro ceed i n t h is m atte r b y d efa u lt a s t h e r e su lt of R esp onden t's f a ilu re t o s u b m it r e sp onsib le A nsw ers t o I n te rro gato rie s a n d a R ep ly t o t h e R eq uest fo r P ro ductio n o f D ocu m en ts w hic h w ere s e rv ed o n _ __ __________.2 64 . In t h e a lte rn ativ e, d ir e ctin g t h at R esp ond en t b e c o m pelle d t o p ro vid e t o P etitio ner re sp onsiv e A nsw ers t o P etit io ner's I n te rro gato rie s a n d R eq uest f o r P ro ductio n o f D ocu m en ts w hic h - 8 - were s e rv ed o n _ _________ ___, w ith in f iv e ( 5 ) d ay s a fte r s e rv ic e o f t h e c o urt's O rd er u pon h im , o r be f o und i n c o n te m pt o f c o u rt, t o geth er w ith o th er s a n ctio ns p erm itte d u nder R ule 3 7.A M EN DIN G J U DGM EN T A ND D EC REE:1 65 . Am en din g p ara g ra p h _ ____________ o f t h e J u dgm en t a n d D ecre e e n te re d b y t h e ab ove c o urt o n _ __________ __, i n t h e a b ove-c ap tio ned p ro ceed in g t o g ra n t t h e l e g al a n d p hysic al cu sto dy o f t h e m in or c h ild re n t o P etitio ner.2 66 . Am en din g p ara g ra p h _ ____________ o f t h e J u dgm en t a n d D ecre e e n te re d b y t h e co urt o n _ ____________ , i n t h e a b ove-c ap tio ned p ro ce ed in g, d ir e ctin g R esp onden t t o p ay t o Petitio ner a r e aso nab le s u m o f m oney a s a n d f o r s u pport o f s a id m in or c h ild re n .3 67 . Dir e ctin g t h at t h e J u dgm en t a n d D ecre e d ate d _ ____________ b e a m en ded a t pa ra g ra p h _ ____________ t o r e ad a s f o llo w s: _ _______ _____ p urs u an t t o R ule 6 0.0 2(1 ), ( 3 ) a n d (6 ) a n d a p plic ab le l a w .4 68 . Dir e ctin g t h at t h e J u dgm en t a n d D ecre e d ate d _ ____________ b e a m en ded a t pa ra g ra p h _ ____________ a s f o llo w s: _ ____________S T A Y A ND N EW T R IA L:1 69 . Gra n tin g a S ta y o f t e rm s _ ___________ _ a n d _ ____________ o f t h e J u dgm en t a n d Decre e d ate d _ __________ __, p en din g f u rth er d ete rm in atio n b y t h e c o urt, p urs u an t t o R ule 6 2.2 70 . In t h e a lte rn ativ e, g ra n tin g a n ew t r ia l o f t h e m ain te n an ce a n d p ro perty i s su es pu rs u an t t o R ule 5 9.C O NCLU SIO N:1 71 . Gra n tin g t o P etitio ner s u ch o th er a n d f u rth er r e lie f a s t h e c o urt m ay d eem j u st a n d eq uita b le i n t h e c ir c u m sta n ce s. S aid M otio n w ill b e m ad e u pon t h e a tta ch ed A ff id av it o f _ ____________, a ll o f t h e f ile s, re co rd s a n d p ro ceed in gs h ere in , a n d t h e s ta tu te s o f t h e S ta te o f M in neso ta .P etitio ner r e q uests t h e r ig ht p urs u an t t o M in neso ta S ta tu te S ectio ns 5 18.1 31, S ubd. 8 , t o intr o duce o ra l t e stim ony, i n s u pple m en ta tio n o f t h e A ff id av its h ere in a s m ay b e n ecessa ry . - 9 - All r esp on siv e p le a d in gs s h all b e s e rv ed a n d m aile d t o o r f ile d w it h t h e c o u rt ad m in is tr a to r n o l a te r t h an f iv e d ays p rio r t o t h e s c h ed ule d h ea rin g. T he c o u rt m ay, i n i t s dis c retio n , d is r eg ard a n y r esp on siv e p le a d in gs s e rv ed o r f ile d w it h t h e c o u rt a d m in is tr a to r le ss t h an f iv e d ays p rio r t o s u ch h ea rin g i n r u lin g o n t h e m otio n o r m atte r i n q uestio n . D ate d :_ _ ____________ _ _________________ A tto rn ey f o r ( A ddre ss)(A ddre s)(C ity , S ta te , Z ip )(P hone N um ber)(A tto rn ey R eg . N o.: ) A CK NO W LED G EM EN T M IN N. S T A T. S E C . 5 49.2 1 T he u nders ig ned h ere b y a ck now le d ges t h at c o sts , d is b urs e m en ts , a n d r e aso nab le a tto rn ey an d w itn ess f e es m ay b e a w ard ed p urs u an t t o M in n. S ta t. S ec. 5 49.2 1, s u bd. 2 , t o t h e p arty a g ain st wh om t h e a lle g atio ns i n t h is p le ad in g a re a sse rte d , i f t h is p arty o r h is o r h er a tto rn ey a cte d i n b ad faith ; a sse rte d a c la im o r d efe n se t h at i s f riv olo us a n d t h at i s c o stly t o t h e p arty ; a sse rte d a n un fo und ed p ositio n s o le ly t o d ela y t h e o rd in ary c o urs e o f t h e p ro ceed in gs o r t o h ara ss; o r c o m mitte d a f ra u d u pon t h e c o urt. D ate d : _ ______ _______ _ __________________ A tto rn ey f o r ( A ddre ss)(A ddre ss)(C ity , S ta te , Z ip )(T ele p hone N um ber)