Fill and Sign the Judgment of the Full Order of Protection Adult This Missouri Courts Form

OSCA (02-16 ) AA52 1 of 1 455.060, 455.065 RSMo IN THE _______ JUDICIAL CIRCUIT , __________ _______________________, MISSOURI Judge or Division: Case Number: (Date File Stamp) Court ORI Number: Petitioner: MSHP Number: Responsible Law Enforcement ORI: vs. Related Cases: Respondent: Alias/Nicknames: Respondent’s Home Address: Home Phone Number: Respondent’s DOB: Respondent’s Work Address: Work Phone Number: Work Hours: SSN (if known , last four digits ): Race: Sex: F M Petitioner’s Relationship to Respondent pursuant to 18 U.S.C. §§ 921(a)(32) and 922(g)(8) determination: Spouse Child(ren) in common Former spouse Intimate residing/resided together Are/were in a continuing social relationship of a romantic/intimate nature Related by blood. Define relationship: Related by marriage. Define relationship: Residing/resided together; no intimacy Stalking /Sexual Assault . Define relationship: Affidavit of Changes in Circumstance and Motion to Modify Judgment Entry Full Order of Protection - Adult A Judgment of the Full Order of Protection - Adult was entered in ____________________________ County, Missouri, on ____________________________ (date). A change has occurred in the circumstances of the petitioner, respondent or child(ren) a nd the modification is necessary to serve the best inter ests of the parties. Below are the specific facts, including dates and times, which petitioner respondent believes forms grounds for modification of the court’s judgment: I request that the court find grounds for modification of: (check the box that applies) Installments of maintenance or support. Conditions regarding communication. Custody. Conditions regarding contact. Visitation. Other (specify): __________________________________________ _____________________ __________________ ________ . The specific modification that I am requesting is: I swear /affirm under penalty of perjury that these facts are true according to my best knowl edge and belief. _________________________________________ Date _________________________________________________ Your Signature _________________________________________________ Your Street Address _________________________________________________ City State Zip _________________________________________________ Your Telephone Number NOTICE: Section 455.030.3 , RSMo , provides that a Petitioner seeking protection under the Domestic Violence Act is not required to reveal any current address or place of residence on this motion. Do not provide this information if doing so will endanger you. In witness thereof: _______________________________ _________________________________________________ Date Clerk Witnessing Signature (Seal) Subscribed and sworn to before me on ___________________________________ (date). My commission expires: __________________ ___________________________________ Date Notary Public Directions for Completing This affidavit must be completed and signature witnessed by a court clerk or notary before filing it with the court.