Fill and Sign the Notice to Petitioner Respondent Will Receive a Copy of This Petition with Service Form

OSCA (01-1 7) A A40 (ASPO) 1 of 4 455.010, 455.030, 455.030.3, 455.050 RSMo IN THE ____ ____ JUDICIAL CIRCUIT , ___ ___________ _________ COUNTY , M ISSOURI Petition for Orde r of P rotection - Adult Notice to Petitioner: Respondent will receive a copy of this petition with service. 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: Age: Respondent’s Work Address: Work Phone Numbe r: Work Hours: SSN (if known , last four digits ): Race: Sex: F M Hair Color: Height: Eye Color: Weight: Other Locations Where Respondent May Be Served: (Identifying information for use by Law Enforcement) Visible Identifying Marks (e.g. tattoos, birthmarks, braces, mustache, beard, pierced ear, glasses): 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: I. PETITIONER INFORMATION 1.I am Petitioner and at least 17 years of age under 17 but emancipated 2. I reside in _______________________________________________ (city), ______________________________ (state), in the County of _____________________________. II. RESPONDENT INFORMATION 3.Respondent is at least 17 years of age or emancipated under 17 4. Respondent may be found in ________________________________________ (city), ________________________ (state), in the County of ___________________________ __. III. LOCATION WHERE DOMESTIC VIOLENCE , STALKING , OR SEXUAL ASSAULT OCCURRED 5. An act of domestic violence , stalking , or sexual assault occurred at ______________________________________ (address), _______________________________ (city), _____________ (state), in the County of ______________________________. OSCA (01-1 7) A A40 (ASPO) 2 of 4 455.010, 455.030, 455.030.3, 455.050 RSMo IV. COMPLETE FOR DOMESTIC VIOLENCE PETITION ONLY Relationship with Respondent 6.Respondent and I: (check one or more) reside together. previously resided together at ________________________________________________________________ (address), _________________________________________________ (city), _____________________________ (state), in the County of _______________________________________. never resided together. Residency 7.The residence in which I live is: (check one or more) jointly owned, leased or rented or jointly occupied by Respondent and me. owned, leased, rented or occupied by me. jointly owned, leased, rented or occupied by me and someone other than Respondent. owned, leased, rented or occupied by someone else, and Respondent is my spouse. jointly occupied by me and another person, and Respondent has no property interest therein. Custody List only the children that the Petitioner and Respondent have in common. The court cannot change custody if a prior order regarding custody is pending or has been made. 8. It is in the best interest of the minor children that custody be awarded as follows: Child’s Name SSN (last 4 digits only) Age Address (If other than Petitioner) 1. ______________________________________ _______________ _____ ________________________ 2. ______________________________________ _______________ _____ ________________________ 3. ______________________________________ _______________ _____ ________________________ 4. ______________________________________ _______________ _____ ________________________ 5. ______________________________________ _______________ _____ ________________________ Who did each Child reside with during last six months Persons to Receive Custody Custody (check one or both) Temporary Full 1. ______________________ _______________________ ______ 2. ______________________ _____________________________ 3. ______________________ _____________________________ 4. ______________________ _____________________________ 5. ______________________ _____________________________ (If necessary, attach additional sheets.) V. COMPLETE FOR STALKING OR SEXUAL ASSAU LT PETITION ONLY 9.Respondent is stalking or sexually assaulting me. Explain relationship (example: co -workers, neighbors, etc.) VI. COMPLETE FOR ALL CASES 10.Indicate any prior or pending custody court cases before, or orders entered by, this court or any other court involving the following parties. Indicate the case numbers. (If none, so state): a. Petitioner _______________________________________________________________________________________ b. Respondent _____________________________________________________________________________________ c. Children (identified in item 8) _____________________ ___________________________________________________ OSCA (01-1 7) A A40 (ASPO) 3 of 4 455.010, 455.030, 455.030.3, 455.050 RSMo A cts Committed by Respondent : 11. Respondent has knowingly and intentionally: (check at least one) caused or attempted to cause me physical harm placed or attempted to place me in apprehension of immediate physical harm coerced me stalked me harassed me sexually assaulted me unlawfully imprisoned me followed me from place to place threatened to do any of the above by the following act(s): (Include the most recent date(s) of each act describe d.) 12. I am afraid of Respondent and there is an immediate and present danger of domestic violence to me or other good cause for an emergency temporary order of protection because: (describe) 13. Photographs/Exhibits are filed as evidence of my injuries. VII. PETITIONER’S REQUESTS 14. Order Petitioner’s residential address on voter’s registration record to be closed to the public. 15.Pursuant to sections 455.010 - 455.085 RSMo, it is requested that the court issue an Ex Parte Order of Protection restraining Respondent from: (check all that apply) committing or threatening to commit domestic violence , sexual assault, molesting, or disturbing the peace of Petitioner wherever Petitioner may be found. stalking Petitioner. entering the dwelling of Petitioner located at (see notice below) _______________________________________________ _____________________________________________________________________________________________ ____. entering the premises of the Petitioner’s school, located at _______________ ___________________________________. entering onto the premises of the Petitioner’s place of employment, located at _________________ ________ __________ . come within ____________ (feet) of the Petitioner. communicating with Petitioner in any manner or through any medium. other: Additional Requests: It is further requested that, upon the hearing of this cause, the court also issue a Full Order of Protection enjoining Respondent from the above acts for such time as is necessary to protect Petitioner and that the cour t: (one or more may be selected) Custody 16. Awa rd custody of the minor child(ren) to Petitioner Respondent. 17. Order visitation with the minor child(ren) to Petitioner Respondent as follows: Child S upport/Maintenance 18. Order Petitioner Respondent to pay child support to Petitioner Respondent in the amount of $ ____________ (check one) p er week per month. 19. Order Petitioner Respondent to pay maintenance to Petitioner Respondent in the amount of $ ____________ (check one) per week per month. OSCA (01-17 ) AA40 (ASPO) 4 of 4 455.010, 455.030, 455.030.3, 455.050 RSMo Other Support 20. Order that Respondent make or continue to make the rent or mortgage payments in the amount of $ ____ __________ (check one) per week per month on the residence occupied by Petitioner. 21. Order that Respondent pay Petitioner’s rent at a residence, other than the residence previous ly shared with Respondent, in the amount of $ _______________ (check one) per week per month. 22. Order Respondent to pay a reasonable fee for housing and other services provided to Petitioner by a shelt er for victims of domestic violence. 23. Order Respondent to pay the cost of medical treatment or services provided to Petitioner as a result of injuries sustained by an act of domestic violence committed by Respondent. Personal Property 24. Order that Petitioner be given temporary possession of the following personal property: 25. Prohibit Respondent from transferring, encumbering, or otherwise disposing of the follow ing property mutually owned or leased with Petitioner: Co unseling/Treatment 26. Order Respondent to participate in a court -approved counseling program designed for batterers and/or substance abuse . Costs/Fees 27. Order Respondent to pay court costs. 28. Order Respondent to pay Petitioner’s attorney fees. Other Order s 29. Order the full order of protection issued for one year be automatically renewed unless Respondent requests a hearing by 30 days prior to the expiration of the order. 30. Petitioner to receive wireless telephone number(s) and billing responsibilities fr om Respondent. (Note: If checked, complete the Wireless Telephone Number Transfer Addendum form.) 31 . Other (specify): VIII. PETITIONER’S SIGNATURE I swear/affirm under penalty of perjury that these facts are true according to my best knowl edge and belief. I understand that a copy of this petition will be served on the respondent. _________________________________________________ Date 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. __________________________________________________ Petitioner’s Signature __________________________________________________ Address (Optional) __________________________________________________ City, State and Zip __________________________________________________ Telephone __________________________________________________ Attorney’s Name, Missouri Bar No., if Applicable __________________________________________________ Address __________________________________________________ City, State and Zip __________________________________________________ Telephone