Fill and Sign the Petition Family Offense Form

F.C.A. §§ 812, 818, 821 Form 8-2 (Family Offense Petition) (12/2013) FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF .......................................................................................... Petitioner Docket No. -against- FAMILY OFFENSE PETITION Respondent ............................................................................................ TO THE FAMILY COURT: The undersigned Petitioner respectfully states that: 1. a. I reside at [specify address unless confidential]: 1 b. The Respondent resides at [specify address unless confidential]: 2. a.  The Respondent and I are related as follows [check all applicable box(es)]:  we are married  we were married  we have a child in common  we are parent and child  we are related by blood or marriage [specify how]:  we are in an intimate relationship (NOT casual social or business acquaintances) [describe]:  we were in an intimate relationship (NOT casual social or business acquaintances) [describe]:  we live together  we lived together in the past  we never lived together b.  Petitioner is a duly authorized agency, association, society or institution and is filing this petition pursuant to F.C.A. §822(b).  c.  I am a peace officer and am filing this petition pursuant to F.C.A. §822(c). 3. The Respondent committed the following family offense(s) against me and/or my children, which constitute(s): Disorderly conduct ❒ Menacing in the second or third degree ❒ Harassment in the first or second degree ❒ Reckless endangerment ❒ Aggravated harassment in the second degree Stalking ❒ ❒ ❒ Assault in the second or third degree Attempted assault ❒ ❒ 1 If your health or safety or that of your child or children would be put at risk by disclosure of your address or other identifying information, you may apply to the Court for an address confidentiality order by submitting General Form GF-21, which is available on-line at www.nycourts.gov. See Family Court Act §154-b. Criminal mischief Sexual misconduct❒ Sexual abuse in the second ❒ 2 or third degree Forcible touching ❒ ❒ Strangulation ❒ Criminal obstruction of breathing or circulation 2 Where victim is incapable of consent for reason other than being under age 17 [Penal Law §130.60(1)]. ❒ Identity theft in 1st , 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)] [Describe each incident; starting with the most recent incident; state date, time and location of each incident; specify all injuries and if any weapons were used. Use additional sheets where necessary]: 4. I  ❑  have have not filed a criminal complaint concerning these incident(s) ❑ [If so, please indicate court, county, date, charge(s) and status, if known]: 5. [Check applicable box(es)]: a. I have no children and there are no other children living in my home. ❑ ❑ b. The following children live with me [include children who are not yours]: Name Date of Birth Relationship to Me Relationship to Respondent ❑ c. The following children are mine but do not live with me. Name Date of Birth Lives With Child’s Relationship to Respondent, if any ❑ d. The Respondent committed family offenses against the above child or children as follows [describe including name(s) of child or children, nature of offense(s) and date(s)]: 3 [Check boxes and complete any of the following paragraphs 6-13 that apply to you. Skip any that do not apply to you.] ❑ 6. The Respondent has acted in a way I consider dangerous or threatening to me, my children, a member of my family or household or person with whom I have or had an intimate relationship, in addition to the incident(s) described in question 3, as follows [describe]: ❑ 7. The Respondent was found to have violated an Order of Protection issued on behalf of me, my children, a member of my family or household or person with whom I have or had an intimate relationship as follows [describe]: 3 Family offenses, when committed against a member of the same family or household or intimate partner, include the crimes of: assault or attempted assault, aggravated harassment or harassment, disorderly conduct, menacing, reckless endangerment, stalking, sexual abuse, sexual misconduct, forcible touching, strangulation, criminal obstruction of breathing or blood circulation, criminal mischief, grand larceny, identity theft and coercion. ❑ 8. The Respondent owns or has access to guns as follows [describe]: 9. ❑ a. The Respondent has a gun license or pistol permit for the following gun(s) as follows [describe]: ❑ b. The Respondent has a gun license or permit application pending as follows [describe]: ❑ c. The Respondent carries a gun on his or her job as follows [describe] : 10. ❑ a. The Respondent threatened [check applicable box(es)] : ❑ me   my child or children [specify ]: ❑ a member or members of my household [specify]: ❑ someone with whom I have or had an intimate relationship [ specify]: with a gun or dangerous instrument or object as follows [specify] : ❑ b. There is a substantial risk that Respondent would use or threaten to use a firearm or dangerous instrument or object against me, my child(ren), a member of my household or person with whom I have or had an intimate relationship on the basis of the following facts and for the following reasons [describe ]: ❑ 11. The following court cases are pending between me and the Respondent [specify court, county, docket or index number, nature of action and status, if known]: ❑ 12. The Respondent has the following criminal convictions [specify, including date, crime, sentence and court, if known]: ❑ 13. [Applicable where protection is sought for pet(s)]: a. The following pets live in my house [specify name(s) and type(s)]: b. The Respondent injured or tried or threatened to injure pets in my household as follows [describe]: 14. I have not made any previous application to any court or judge for the relief requested in this petition, (except [specify the relief, if any, granted and the date of such relief; delete if inapplicable]: ). WHEREFORE, Petitioner respectfully requests this Court to: a. adjudge the Respondent to have committed the family offense(s) alleged; b. enter an order of protection, specifying conditions of behavior to be observed by the Respondent in accordance with Section 842 of the Family Court Act; c. enter a finding of aggravated circumstances [delete if inapplicable]; d. enter a temporary order of child support in accordance with Family Court Act §828(4) [delete if inapplicable]; e. order such other and further relief as to the Court seems just and proper. Dated: Petitioner: (print or type name) / Signature Petitioner’s Attorney, if any (print or type name) / Signature Address and telephone number of Attorney, if any