Supplemental Affidavit in Support of Petition for Injunction

Florida Supreme Court Approved Family Law Form 12.980(q) - Petition for Injunction for Protection Against Sexual Violence

Instructions: Complete this form in black ink or type it. If you fear that disclosing your address would put you in danger, complete a Request for Confidential Filing of Address and write confidential in the address space provided.

IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT,

IN AND FOR COUNTY, FLORIDA

,

Petitioner,

and

,

Respondent,

PETITION FOR INJUNCTION FOR PROTECTION AGAINST SEXUAL VIOLENCE

I, being sworn, certify that the following statements are true:

SECTION I. PETITIONER

(This section is about you. It must be completed; however, if you fear that disclosing your address to the respondent would put you in danger, you should complete and file a Request for Confidential Filing of Address and write confidential in the space provided on this form for your address.)

1. Petitioner currently lives at the following address:

Date of Birth of Petitioner:

[Indicate if applicable]

Petitioner seeks an injunction for protection on behalf of a minor child. Petitioner is the parent or legal guardian of , a minor child who is living at home.

2. Petitioner's attorney's name, address, and telephone number is:

SECTION II. RESPONDENT

(This section is about the person you want to be protected from. It must be completed.)

1. Respondent currently lives at the following address:

Respondent’s Driver’s License number is:

2. Respondent's last known place of employment:

Employment address:

Working hours:

3. Physical description of Respondent:

Race: Sex: Male Female Date of Birth:

Height: Weight: Eye Color: Hair Color:

Distinguishing marks and/or scars:

Vehicle (make/model): Color: Tag Number:

4. Other names Respondent goes by (aliases or nicknames):

5. Respondent's attorney’s name, address, and telephone number is:

6. If Respondent is a minor, the address of Respondent’s parent or legal guardian is:

SECTION III. CASE HISTORY AND REASON FOR SEEKING PETITION

(This section must be completed.)

1. Petitioner has suffered sexual violence as shown by the fact that the Respondent has:

Please indicate here if you are attaching additional pages to continue these facts.

[Indicate all that apply]

a. Petitioner reported the sexual violence to law enforcement and is cooperating in any criminal proceeding. The incident report number by law enforcement is: {If there is a criminal case, include case number, if known}

b. Respondent was sent to prison for committing sexual violence against Petitioner or Petitioner’s minor child living at home and Respondent is out of prison or is getting out of prison within 90 days. The notice of inmate release is attached.

2. Has Petitioner ever received or tried to get an injunction for protection against domestic violence, dating violence, repeat violence, or sexual violence against Respondent in this or any other court?

Yes No

3. Has Respondent ever received or tried to get an injunction for protection against domestic violence, dating violence, repeat violence, or sexual violence against Petitioner in this or any other court?

Yes No

4. Describe any other court case that is either going on now or that happened in the past between Petitioner and Respondent:

Additional Information

[Indicate all that apply]

a. Respondent owns, has, and/or is known to have guns or other weapons.

Describe weapon(s):

b. This or prior acts of violence have been previously reported to:

SECTION IV. INJUNCTION

(This section must be completed.)

1. Petitioner asks the Court to enter a TEMPORARY INJUNCTION for protection against sexual violence that will be in place from now until the scheduled hearing in this matter.

2. Petitioner asks the Court to enter an injunction prohibiting Respondent from committing any acts of violence against Petitioner and:

a. prohibiting Respondent from going to or within 500 feet of any place Petitioner lives;

b. prohibiting Respondent from going to or within 500 feet of Petitioner’s place(s) of employment or the school that Petitioner attends; the address of Petitioner's place(s) of employment and/or school is:

c. prohibiting Respondent from contacting Petitioner by telephone, mail, by e-mail, in writing, through another person, or in any other manner;

d. ordering Respondent not to use or possess any guns or firearms;

[Indicate all that apply]

e. prohibiting Respondent from going to or within 500 feet of the following place(s) Petitioner or Petitioner’s immediate family must go to often:

f. prohibiting Respondent from knowingly and intentionally going to or within 100 feet of Petitioner’s motor vehicle; AND any other terms the Court deems necessary for the safety of Petitioner and Petitioner’s immediate family.

I UNDERSTAND THAT BY FILING THIS PETITION, I AM ASKING THE COURT TO HOLD A HEARING ON THIS PETITION, THAT BOTH THE RESPONDENT AND I WILL BE NOTIFIED OF THE HEARING, AND THAT I MUST APPEAR AT THE HEARING. I UNDERSTAND THAT IF EITHER RESPONDENT OR I FAIL TO APPEAR AT THE FINAL HEARING, WE WILL BE BOUND BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED AT THAT HEARING.

I UNDERSTAND THAT I AM SWEARING OR AFFIRMING UNDER OATH TO THE TRUTHFULNESS OF THE CLAIMS MADE IN THIS PETITION AND THAT THE PUNISHMENT FOR KNOWINGLY MAKING A FALSE STATEMENT INCLUDES FINES AND/OR IMPRISONMENT.

STATE OF FLORIDA

COUNTY OF

Sworn to or affirmed and signed before me on by