Fill and Sign the Petitioners Affidavit and Petition for Order for Protection Ofp Form

OFP102 State ENG Rev 12/15 www.mncourts.gov/forms Page 1 of 12 State of Minnesota District Court County Judicial District: Court File Number: Case Type: Domestic Abuse In the Matter of: Petitioner (first, middle, last ) Petitioner’s Affidavit and Petition On behalf of: For Order for Protection Other persons needing protection (first, middle, last) Minn. Stat. § 518B.01 and for her/himself vs. Respondent (first, middle, last) STATE OF MINNESOTA ) ) SS COUN TY OF ) (county where affidavit signed) I, _________________________________________ , state that: I am the Petitioner (the person requesting the order) in this action. This affidavit supports my request for an Order for Protection (OFP). (Minn. St at. § 518B.01). 1. Who needs protection? Me (Petitioner) My minor child(ren) A person for whom I am the legal guardian (attach Guardianship Order) A minor child who is not my child, but is a family or household member of mine Other: 2. Petitioner Information (You) Name: (first, middle , last) My address or phone is confidential. (Give the confidential information to court administration on a se parate sheet of paper.) My Address: OFP102 State ENG Rev 12/15 www.mncourts.gov/forms Page 2 of 12 City, State, Zip Code : Telephone: (__________) Race:____________________________ (for federal reporting purposes) Gender: male female Date of birth: (month/day/ye ar) : 3. Email Notification of Service By providing my email address below, I am indicating that I want to be notified by email when the respondent is served with the O FP. I understand that this is the only email I will receive from the court about the O FP unless I have signed up to receive other court notices via email. I understand that it will only be possible for the court to notify me by email when service information is received by the court. I understand that a technical or other error could occu r preventing the successful delivery of the email, and that I have other options to learn of the service of the OFP on the respondent, including contacting law enforcement directly. I understand I must provide a valid email address in order to receive thi s notification of service , and that THIS EMAIL ADDRESS WILL BE SEEN BY THE RESPONDENT : Email address: 4. Respondent Information: (Person you want protection from) Name: (first, middle, last) Address: City, State, Zip Co de Telephone: (__________) Race: ____________________________ Gender: male female Date of birth: If unknown, age or approximate age mo nth/day/year If Respondent is under 18 years old, servic e must be made on Respondent and Respondent’s parent or guardian. Parent or guardian name: Parent or guardian address : 5. List all persons needing protection , other than you. None Name (first, middle, last) Race Gender Da te of Birth Lives with you? How is this person related to you? How is this person related to Respondent? M F Yes No M F Yes No OFP102 State ENG Rev 12/15 www.mncourts.gov/forms Page 3 of 12 M F Yes No M F Yes No M F Yes No 6. List all minor children you and Respondent have together (biological and adopted), not listed at # 5. None Name (first, middle, last) Date of Birth Who has the child now? Me Respondent Other Me Respondent Other Me Respondent Other Me Respondent Other Me Respondent Other 7. List all minor children living with you, not listed at # 5 or # 6. None Name (first, middle, last) Date of Birth How is this child related to you? How is this child related to Respondent? 8. What is your relationship to Respondent? (Check all that apply) Married. Marriage date: _____________________________ Divorced. Marriage date: _________________ Divorce date: __________________ ___ Living together since _______________________(date) Lived together from ______/_____/________ to ______/______/____________ Have a child together Have an unborn child together Parent/Child Related by blood Significant romantic or sexual relationship . OFP102 State ENG Rev 12/15 www.mncourts.gov/forms Page 4 of 12 The relationship lasted from (date) :______________ __ _ until How often did you have contact with Respondent during that time? 9. Is there an Order for Protection in effect now between you (or anyone else listed at # 5) and Respondent? Yes No If yes, whe n does the Order expire? In what County and State was the Order made? What is the Court Case Number? The Order requires (name) _________________________________ _ to stay away from (names) 10. Orders for Protection no longer in effect: Have yo u, or any of the people listed at # 5, had an Order for Protection against Respondent in the past? Yes No (I f no, skip to # 11.) If yes, how many? ________________________ (If a temporary order expired because law en forcement was not able to serve Respondent with the OFP, you do not have to list it here.) Provide the following details: Court File Number, if known County and State 11. Now, or in the past, have you (or other persons at # 5) and Respondent been joi ntly involved in other family court, domestic abuse criminal cases, or harassment restraining order cases ? Yes No Check the box if you and Respondent have a current or closed Court Case of this type: Di vorce Custody Paternity Child Support Child Protection Domestic Abuse criminal charges Domestic Abuse criminal conviction Harassment Restraining Order For each box checked, provide the following case information , if known : Case Type Case Number State/ County Year Filed Names of Children involved ____________________________________________________________ _______________ ___________________________________________________________________________ OFP102 State ENG Rev 12/15 www.mncourts.gov/forms Page 5 of 12 ___________________________________________________________________________ 12. Why do you (or the persons listed at # 5) need an Order for Protection? Describe the a buse by answering the questions below. If there are several dates, use the Description of Abuse Attachment to describe what happened on the other dates. Date of most recent abuse: ________________________________________________ ____ _ Who was there: ____ ____________________________________________________ ___ __ Describe what Respondent did to physically harm you (or others at # 5) or make you afraid. If you were injured, also describe the injuries. _______________________________ ____ ____ _______________ ___ ____________________________________ ____________________ _ __________________________________________________________________________ _ __________________________________________________________________________ _ Was medical treatment received for any injurie s? Yes No If Yes, list the dates and locations where medical treatment was received.__________________________________ __ ___________________________________________________________________________ Describe any use or th reatened use of guns or other weapons : _______________________ __ ___________________________________________________________________________ During the incident, did Respondent interfere with a 911 or emergency call? Yes No Describe the interference: ______________________________________________ __ _____ Did the police/sheriff come? Yes No If Yes, list dates and other details. __________ _ ____________________________________ _______________________________________ 13. (Optional) If there is a history of abuse by Respondent against persons at # 5, in addition to the recent incidents, you may briefly explain the history her e: ______________________ __ _ _______________________________ ___________ _________________________________ __________________________________________ _________________________________ 14. Do you believe that the domestic violence will continue and that you or other persons at # 5 are in immediate danger? Yes No Why? ________ ____________________________ ___________________________________________________________________________ ___________________________________________________________________________ 15. Does Respondent work or attend scho ol at the same place as Petitioner or any other protected persons ? Yes No OFP102 State ENG Rev 12/15 www.mncourts.gov/forms Page 6 of 12 REQUESTS FOR RELIEF 16. Relief that does not require a hearing: I ask the cou rt to order the things I checked below in (a) through (k). I understand that requesting these things does not require a hearing to be held. I understand that if the court issues an Ex Parte Order, the judge may set a hearing and/or the Respondent may request a hearing. I understand that if the court does not issue an Ex P arte Order, the judge may dismiss the matter, or may set a hearing, unless I do not want a hearin g (indicate by checking the box below). I DO NOT want a hearing. I f the court does not issue an Ex Parte Order, I ask that no hearing be s cheduled and that the matter be dismissed. I understand that this means there will be no Order issued and no further proceedings. Based on this affidavit, I am asking the court to make the following orders : a. Issue an Ex Parte Order for Protection to protect me all persons listed at # 5. (These are the protected persons.) b. Restrain and enjoin Respondent from causing the protected person(s) any physical harm, or fear of immediate physi cal harm. c. Order Respondent to have no contact with the protected person(s) whether in person, wi th or through other persons, by telephone, mail, e -mail, through electronic devices, social media, through a third party, or by any other me ans, except as follows : _____________________________________________________________________ ___ _____________________________________________________________________ ___ d. Exclude Respondent from: i. My home or the home Respondent and I share . . My address is confidential OR My home address is: _____________ ___________ _________________________ __________________________________________________________________ And a reasonable area surrounding my home, specifical ly as follows: OFP102 State ENG Rev 12/15 www.mncourts.gov/forms Page 7 of 12 Except as follows: _____________________________________________ _____ __________________________________________________________________ ii. The home of _____________________________________ (protected person(s) ). The address is confidential OR The home address is: _______________ ____________________________________ __________________________________________________________________ __ And a reasonable area surrounding this home, specifically as follows: Except as follows: ____________________________________________ ________ e. Restrain Respondent from calling or entering Petitioner’s BBBBBBBBBBBBBBBB¶V workplace including all land , parking lots and buildings at: Employer Name : Address: Street, City, State Except as follows : ____________________________________________________________________ ____ f. Restrain Respondent from entering ____________ ___ ____ ____________________at the following address:___________________________________ ___ ________________ Street, City, State Except as follows: ____________________________________________________ ___ _ g. Order Respondent to continue all c urrently avail able insurance coverage without change in coverage or beneficiaries. h. Order the possession and care of a pet or companion animal as follows: i. Order Respondent to refrain from physically abusing or injuring any pet or companion animal, without legal justification, known to be owned, possessed, kept, or held by either party or a minor child residing in the residence or household of either party as an indirect means of intentiona lly threatening the safety of such person. j. Direct local law enforcement to provide the following assistance: k. Other: OFP102 State ENG Rev 12/15 www.mncourts.gov/forms Page 8 of 12 17. Relief that requires a hearing In addition to the o rders requested above, I ask the court to order the following things. I understand that if I request any of the following things, a hearing must be held. a. Grant me temporary custody of the joint minor child(ren) subject to parenting time for the Respondent as detailed at #1 8. (Fill out #1 8) b. Order Respondent to pay a reasonable amount of money for the support of our joint minor child(ren). ( Fill out #19) c. Order Respondent to pay a reasonable amount of mon ey to me for my living expenses (Fill out #19) d. Award me temporary use and possession of personal property (describe the property): ____________________________________________________________________ ___ e. Restrain respondent from disposing of or destroying the following property: _______ ____________________________________________________________________ ____ f. Order Respondent to pay me restituti on in the amount of $____ _______ _ (Fill out #20) g. Order Respondent to attend counseling, treatment, or other social services as follows : Domestic Abuse program Alcohol/chemical dependency evaluation and follow recommended treatment Mental health evaluation and follow recommended treatment Other__________________________________________________________ h. Prohibit Respondent from shipping, transporting, possessing, or receiving any firearms or ammunition . i. Issue the Order for Protection for a period up to 50 years because: Respondent has violated a prior or existing Order for Protection on two or more occasions Petitioner /protected person has had two or more Orders for Protection in effect against this Respondent. Additional Information to Support my Request s that Require a Hearing 18. Temporary Custo dy and Parenting Time If you and Respondent have a minor child together, you can ask the court to make temporary orders about custody, parenting time, or support for the child. To ask for these OFP102 State ENG Rev 12/15 www.mncourts.gov/forms Page 9 of 12 temporary orders, paternity must be established by marriage, Recognition of Parentage, or Paternity Order. Do you want custody or parenting time order ed ? Yes No If No, skip to # 19. If Yes, fill in the information below. a. Temporary c ustody of the following joint minor child(ren): ____________ ______ _________ _________________________________________________________ should be awarded to me because: ______________________________ ______ __ __________________________________________________________________ b. Respo ndent should have parenting time as follows: (Check all that apply) Unsupervised parenting time at the following days/times: _______________________________________________________________ _______ ________________________________________________________ _______________________________________________________________ No parenting time because: ________________________________________ ______________________________________________________________ Supervised parenting time because: _________________________________ _______________________________________________________ _______ _____________________________________with supervision as follows: at a safety center or appropriate facility , if available. supervised by a relative, friend, or other third party Parenting time subject to the following conditions: We should exchange the children for p arenting time exchanges at an appropriate facility : Other: 19. Financial Support I want the court to order Respondent to financially support me o r our joint children. Yes No If No, skip to # 20 . If Yes, fill in the information below. OFP102 State ENG Rev 12/15 www.mncourts.gov/forms Page 10 of 12 a. I am seeking child support spousal maintenance medical support/health insu rance. Note: You must be married to get spousal maintenance for your living expenses. My income is $ per month from _________________________ (source). I have monthly expenses of $ , including $ for our joint minor child(ren). Respondent's income is $ per month from (source) or unknown. Respondent is employed un employed unknown. The name and address of Respondent’s employer is: _______________________________________________ ____________________________________________ _________________________ b. I have childcare costs for the joint children of $ ___________ per month because of employment or school. c. Health insurance for me child(ren) is through: My employer Respondent’s employer Minnesota Care Private insurance I purchase Private insurance Respondent purchases Othe r: d. Other information about wh y you want financial support: 20. Restitution I want the Court to order Respondent to reimburse me for expenses I incurred because of the domestic abuse. Yes No If Yes, fill in t he information below. My expenses total $________________________. Describe the expenses (such as medical expenses or costs to repai r or replace damaged property) (Be prepared to bring receipts or other proof of the expenses to the cour t hearing.) OFP102 State ENG Rev 12/15 www.mncourts.gov/forms Page 11 of 12 21. I further request such other relief at the time of the full hearing as the Court finds necessary for the protection of a family or household member, including orders or directives to law enforcement agencies. I declare under penalty of perjur y that everything I have stated in this document is true and correct. Minn. Stat. § 358.116. Signature of Petitioner: Dated: Name: (If your address is confidential do not include it here) Address: City /State/Zip: Telephone: ( ) E-mail address: OFP102 State ENG Rev 12/15 www.mncourts.gov/forms Page 12 of 12 ATTACHMENT FOR DESCRIPTION OF ADDITIONAL ABUSE Date of next incidence of abuse : ___________________ _______________________________ Who was there: ____________________________________ _________________________ ____ Describe what Respondent did to physically harm you (or others at #4) or make you afraid. If you were injured, also describe the injuries. ______________________________________ ____ ____________________________________________ ______________________________ ____ __________________________________________________________________________ ____ __________________________________________________________________________ ____ Was medical treatment received for any injuries? Yes No If Yes, list the dates and locations where medical treatment was received. _______________ _______________________ ___________________________________________________________________________ ___ Describe any use or threatened u se of guns or other weapons: ___________________ _________ ___________________________________________________________________________ ___ During the incident, did Respondent interfere with a 911 or emergency call? Yes No If yes, describe the interference:____ __________________________________________________ Did the police/sheriff come? Yes No If Yes, list dates and other details. ____________ __ __________________________________________ __________________________________ __ Date of next incident of abuse : ____________________________________________ _______ Who was there: _____________________________________________________ ___________ Describe what Respondent did to physically harm you (o r others at #4) or make you afraid. If you were injured, also describe the injuries. ______________________________________ ____ __________________________________________________________________________ ___ _________________________________________________ _________________________ ___ __________________________________________________________________________ ____ Was medical treatment received for any injuries? Yes No If Yes, list the dates and locations where medical tre atment was received.________________ _______________________ ___________________________________________________________________________ ___ Describe any use or threatened use of guns or other weapons: ___________________ _________ ___________________________ ________________________________________________ ___ During the incident, did Respondent interfere with a 911 or emergency call? Yes No If yes, d escribe the interference: _________ ______________________________ __________ ____ Did the police/sheriff come? Yes No If Yes, list dates and other details. __________ ____ ______________________________________________________________________________