Petitioner's Affidavit and Petition for Order for Protection

Petitioner’s Affidavit and Petition For Order for Protection

State of Minnesota

County:

In the Matter of:

Petitioner (first, middle, last):

On behalf of:

and for her/himself

Respondent (first, middle, last):

STATE OF MINNESOTA )

) SS

COUNTY OF

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. Stat. § 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:

My address or phone is confidential. (Give the confidential information to court administration on a separate sheet of paper.)

My Address:

City, State, Zip Code:

Telephone:

Race:

Gender: male female

Date of birth:

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 OFP. I understand that this is the only email I will receive from the court about the OFP unless I have signed up to receive other court notices via email.

Email address:

4. Respondent Information: (Person you want protection from)

Name:

Address:

City, State, Zip Code:

Telephone:

Race: Gender: male female

Date of birth: If unknown, age or approximate age

Parent or guardian name:

Parent or guardian address:

5. List all persons needing protection, other than you. None

6. List all minor children you and Respondent have together (biological and adopted), not listed at #5. None

7. List all minor children living with you, not listed at #5 or #6. None

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. The relationship lasted from until . How often did you have contact?

9. Is there an Order for Protection in effect now between you and Respondent? Yes No

If yes, when 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 Orders for Protection no longer in effect: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 you, or any of the people listed at #5, had an Order for Protection against Respondent in the past? Yes No

If yes, how many?

11. Jointly involved in other family court, domestic abuse criminal, or harassment restraining order cases? Yes No

Check the box if you and Respondent have a current or closed Court Case of this type:

Divorce Custody Paternity Child Support Child Protection

Domestic Abuse criminal charges Domestic Abuse criminal conviction

Harassment Restraining Order

12. Why do you need an Order for Protection?

Date of most recent abuse:

Who was there:

Was medical treatment received for any injuries? Yes No

Describe any use or threatened use of guns or other weapons:

Did Respondent interfere with a 911 or emergency call? Yes No

Did the police/sheriff come? Yes No

13. Optional history of abuse

14. Immediate danger? Yes No

15. Does Respondent work or attend school at the same place as Petitioner or any other protected persons? Yes No

REQUESTS FOR RELIEF

16. Relief that does not require a hearing:

I DO NOT want a hearing. If the court does not issue an Ex Parte Order, I ask that no hearing be scheduled and that the matter be dismissed.

Issue an Ex Parte Order for Protection to protect me all persons listed at #5.

Restrain and enjoin Respondent from causing the protected person(s) physical harm or fear of immediate physical harm.

Order Respondent to have no contact with the protected person(s), 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, specifically as follows:

Except as follows:

ii. The home of .

The address is confidential OR

The home address is:

And a reasonable area surrounding this home, specifically as follows:

Except as follows:

Restrain Respondent from calling or entering Petitioner’s workplace including all land, parking lots and buildings at:

Employer Name:

Address:

Except as follows:

Restrain Respondent from entering at the following address:

Street, City, State:

Except as follows:

Order Respondent to continue all currently available insurance coverage without change in coverage or beneficiaries.

Order the possession and care of a pet or companion animal as follows:

Order Respondent to refrain from physically abusing or injuring any pet or companion animal.

Direct local law enforcement to provide the following assistance:

Other:

17. Relief that requires a hearing

Grant me temporary custody of the joint minor child(ren) subject to parenting time for the Respondent as detailed at #18.

Order Respondent to pay a reasonable amount of money for the support of our joint minor child(ren).

Order Respondent to pay a reasonable amount of money to me for my living expenses.

Award me temporary use and possession of personal property:

Restrain respondent from disposing of or destroying the following property:

Order Respondent to pay me restitution in the amount of $

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

Prohibit Respondent from shipping, transporting, possessing, or receiving any firearms or ammunition.

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.

18. Temporary Custody and Parenting Time

Do you want custody or parenting time ordered? Yes No

Temporary custody of the following joint minor child(ren):

Should be awarded to me because:

Respondent should have parenting time as follows:

19. Financial Support

I want the court to order Respondent to financially support me or our joint children. Yes No

I am seeking child support spousal maintenance medical support/health insurance.

My income is $ per month from

I have monthly expenses of $, including $ for our joint minor child(ren).

Respondent's income is $ per month from or unknown. Respondent is employed unemployed unknown.

The name and address of Respondent’s employer is:

I have childcare costs for the joint children of $ per month because of employment or school.

Health insurance for me/child(ren) is through:

My employer

Respondent’s employer

Minnesota Care

Private insurance I purchase

Private insurance Respondent purchases

Other:

Other information about why 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

My expenses total $

21. Other relief

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.

ATTACHMENT FOR DESCRIPTION OF ADDITIONAL ABUSE

Date of next incidence of abuse:

Who was there:

Was medical treatment received for any injuries? Yes No

Describe any use or threatened use of guns or other weapons:

Did Respondent interfere with a 911 or emergency call? Yes No

Did the police/sheriff come? Yes No

Date of next incident of abuse

Who was there:

Was medical treatment received for any injuries? Yes No

Describe any use or threatened use of guns or other weapons:

Did Respondent interfere with a 911 or emergency call? Yes No

Did the police/sheriff come? Yes No