Fill and Sign the Districtsuperior Court for the State of Alaska at Form

This is Not a Court Order AS 18.66.100-.990/ Page 1 of 7 DV-100 (7/17)(cs) PETITION FOR DOMESTIC VIOLE NCE PROTECTIVE ORDER(S) (ONE PETITIONER) Civil Rule 65.1 IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA AT ) ) PETITIONER (protected person), M F ) Birthdate: ) Petitioner is a child. Who is signing for the child? ) Name: Birthdate: ) Relationship to child: ) v. ) ) Case No. CI ) RESPONDENT (restrained person), M F ) Birthdate ) PETITION FOR Respondent is a child. Who is signing for the child? ) DOMESTIC VIOLENCE Name: Birthdate: ) PROTECTIVE ORDER(S) Relationship to child: ) (ONE PETITIONER) ) 1. TYPE OF ORDER. Select the type of order being requested. Select both the 20-day order and the long-term order if petitioner wants a protective order for more than 20 days. 20-day protective order A 20-day order can take effect immediately and without prior notice to the respondent. Did you notify respondent before filing this petitio n? yes no Describe your efforts, if any, to notify respondent before filing this petition: Long-term protective order A long-term order may be issued after notice to respondent and a court hearing, an d will usually last for one year. 2. HOW ARE PETITIONER AN D RESPONDENT RELATED? (Check all that apply.) a. Married to each other now or in the past b. Child together c. Living together now or in the past (but not also dating or sexual relationship) d. Dating or sexual relationship now or in the past (but not also living together) e. Living together and dating or sexual relationship now or in the past f. Related by marriage now or in the past (such as in-laws) g. Other family relationship, respondent is petitioner’s child or step child parent step-parent grandchild grandparent first cousin uncle or aunt niece or nephew brother or sister other relative (describe) h. Petitioner is a child of a person in a relationship described in (a) through (g) above This is Not a Court Order AS 18.66.100-.990/ Page 2 of 7 DV-100 (7/17)(cs) PETITION FOR DOMESTIC VIOLE NCE PROTECTIVE ORDER(S) (ONE PETITIONER) Civil Rule 65.1 3. Are there children in petitioner’s household? yes no 4. DESCRIBE THE DOMESTIC VIOLENCE. Attac h additional pages if necessary. a. Describe what happened, when it happened, where it happened, and whether children were involved. Please be specific. b. Was a weapon involved? yes no (If yes, describe.) c. Was anyone injured? yes no (If yes, describe.) d. Has respondent been involved in other instances of domestic violence with petitioner or anyone else? yes no (If yes, describe.) This is Not a Court Order Page 3 of 7 DV -100 (7 /17)(cs) AS 18.66.100-.990/ PETITION FOR DOMESTIC VIOLENCE PROTECTIVE ORDER(S) (ONE PETITIONER) Civil Rule 65.1 5. PROTECTIONS REQUESTED. (C heck all that apply.) a. R espondent not to threaten or commit acts of domestic violence, stalking, or harassment. b. R espondent not to telephone, contact, or communicate in any other way, directly or indirectly , with petitioner . Exceptions where it would be safe for the respondent to contact petitioner : no exceptions by email to through an attorney by telephone to through a third person (such as a grandparent ) named other c. R espondent to leave and stay away from petitioner’s residence at this street address: Check this box if you want to keep this address confidential. Does respondent live in this residence too? yes no Does respondent know this address? yes no d . R espondent to stay away from and not telephone or contact the following locations: Place Street Address Distance to Stay Away Petitioner’s school ft. mi. Children’s school ft. mi. Petitioner’s job ft. mi. ft. mi. ft. mi. Exceptions: e. Respondent not to enter, follow, or interf ere with the operation of any vehicle occupied by petitioner or in petitioner’s possession. f. Respondent not to possess or use controlled substances. g . Award p etitioner temporary possession and use of the following, re gardless ofownership : (1) Residence located at and everything in it. (street address) (2) Vehicle and all keys to it. License plate number Vehicle Description (3) Essential pe rsonal items ( check all that apply) : house keys garage door opener children’s belongings mailbox keys clothes medicine children’s medicine toiletries Medicare/Medicaid coupons food stamps pet(s) named birth certificates belonging to passports belonging to immigration documents belonging to ANCSA Corp. ID T ribal enrol lment card C ertificate of Indian blood other This is Not a Court Order AS 18.66.100-.990/ Page 4 of 7 DV-100 (7/17)(cs) PETITION FOR DOMESTIC VIOLE NCE PROTECTIVE ORDER(S) (ONE PETITIONER) Civil Rule 65.1 h. Respondent to pay spousal support to petitioner. How much monthly spousal support is petitioner requesting and why is support necessary? i. Respondent not to sell or dispose of any personal property of the petitioner, anyproperty jointly held, or any disputed property. 6. LONG-TERM PROTECTIONS REQUESTED. In additi on to the protections listed above, petitioner requests that the following be included in the long-term protective order. Note that these requirements cannot be included in the 20-day order. (Check all that apply.) a. Respondent not to use or possess a deadly weapon, including a firearm. b. Respondent to surrender any firearm owned or possessed by respondent. c. Respondent to pay to the costs and fees petitioner paid in bringing this action, in the amount of $ . d. Respondent to pay petitioner or the pers on(s) named below for expenses associated with the domestic violence (such as medical expenses, counseling , shelter, and repair or replacement of damaged property) described below: Pay to Type of Expense Amount $ $ $ e. Respondent to enroll in and complete, at respondent's expense (check all that apply): Program for the rehabilitation of batterers Treatment for substance abuse f. Other requests for long-term protection: 7. CHILDREN. (If petitioner is not requesting custody or child support, skip to question 8.) a. Award petitioner temporary custody of the minor child(ren) named below: (1) Child's Full Name Child’s Petitioner’ s Respondent's Date of Birth Relationship Relationship to Child to Child This is Not a Court Order AS 18.66.100-.990/ Page 5 of 7 DV-100 (7/17)(cs) PETITION FOR DOMESTIC VIOLE NCE PROTECTIVE ORDER(S) (ONE PETITIONER) Civil Rule 65.1 (2) Have the child(ren) lived in Alaska for the past six months? yes no (3) Who has the child(ren)? Petitioner currently has the child(ren). currently has the child(ren). (4) Is there already a custody order about one or more of the children? yes no do not know. If yes, describe each order below: Child's Name State that Case Number Order Grants Issued Order (if known) Custody to b.Visitation. The court may only grant visitation to the respondent if the safety of the petitioner and children can be protected. Descr ibe any safety concerns about visitation. What visitation schedule would work, if any, and where should exchanges take place? c. Child Support . Petitioner requests that the court require the respondent to pay child support: yes no (1) Financial information about respondent Respondent's occupation Name of respondent’s employer Respondent's monthly take-home pay is $ (2) Child support checks should be sent to (mailing address that can be revealed to respondent) Important Note: To get a child s upport order, fill out a Child Support Guidelines Affidavit (court form DR-305, av ailable from the court c lerk or online at http://www.courtrecords.alaska.gov /webdocs/forms/dr-305.pdf), and bring it to each court hearing, together with proof of petitioner’s and respondent’s income if available. If you cannot bring an affidav it, bring proof of income anyway. Proof of income includes documents such as pays tubs, tax returns, W2 forms, and 1099 forms. 8. OTHER CASES.a. List all open domestic violence criminal cases and open civil court cases (such as divorceand custody), in Alaska or elsewhere, that involve either petitioner or respondent: Type of Case Court Location Petitioner or Respondent b. List all other cases, open and closed, that involve respondent: Type of Case Court Location 9. ASSISTANCE FROM LAW ENFO RCEMENT. In addition to the protections listed above, petitioner asks the court to issue an order requiring law enforcement to do the following (check all that apply): a. Accompany and assist petitioner to take possession of the residence identified in paragraph (5)(g)(1) above. Remove respondent from the residence if necessary. b. Accompany and assist petitioner to take possession of the personal items listed in paragraph (5)(g)(3) above. c. Accompany and assist petitioner to take possession of the vehicle identified in paragraph (5)(g)(2) above. d. Assist (name) to obtain custody of the minor child(ren) named in paragraph (7)(a)(1) above. e. Accompany respondent to the residence at (street address) once to recover undisputed personal items, clothing, and Law enforcement to notify petitioner of the time and date they will accompany respondent to the residence. Petitioner may b e present. Any item petitioner objects to respondent removing, law enforcement shall restrain respondent from removing from the residence. 10. INFORMATION ABOUT RESPONDENT. Respondent’s full legal name: Other information about respondent: Sex Race *Date of Birth* HT WT Hair Eyes State ID /Driver’s Lic. # ST Other Identifiers Any nicknames or other names used: Respondent’s mailing/physical address: Respondent’s Phone 1 Respondent’s Phone 2 Respondent’s Employer This is Not a Court Order AS 18.66.100-.990/ Page 6 of 7 DV-100 (7/17)(cs) PETITION FOR DOMESTIC VIOLE NCE PROTECTIVE ORDER(S) (ONE PETITIONER) Civil Rule 65.1 This is Not a Court Order AS 18.66.100-.990/ Page 7 of 7 DV-100 (7/17)(cs) PETITION FOR DOMESTIC VIOLE NCE PROTECTIVE ORDER(S) (ONE PETITIONER) Civil Rule 65.1 11. INFORMATION ABOUT PETITIONER. The court needs petitioner’s mailing address in order to send court papers, including notices of hearing, to petitioner. If petitioner may be endangered by giving petitioner’s mailing address, write a "message" address where petitioner can be sure to receive court papers. If petitioner does not have any address and telephone number that can safely be revealed to respondent, ask the court clerk how petitioner can provide this information so that it will be kept confidential and not revealed to respondent. Petitioner’s full legal name and any nicknames or other names used: Petitioner’s (safe) mailing address: Petitioner’s telephone numbers: Home Work Cell I swear or affirm under penalty of perjury that all the information I provided in this petition is true to the best of my knowledge and belief. Date Petitioner’s Signature Print Name Subscribed and sworn to or affirmed before me at , Alaska on . (date) (SEAL) Clerk of Court, Notary Public or other person authorized to administer oaths My commission expires: CONFIDENTIAL LAW ENFORCEMENT INFORMATION SHEET Notice to Petitioner : You must supply the respondent's name and birt h date, if known. Give as much information as possible. This information will NOT be given to the respondent. Notice to Law Enforcement : This information is confidential and supplie d to assist you in serving the protective order. After serving (or failing to serve) the order, notif y petitioner and complete the return of service section on the DV-125. A. PETITIONER INFORMATION Full name: Date of birth: Petitioner is a child. Petitioner’s residence address: Is this the address respondent is to stay away from? Yes No Do you want to be notified when respondent is served? Yes No Contact phone(s): home work cell msg B. RESPONDENT INFORMATION Full name: Nicknames: Respondent is a child. Residence Address: Is this the address respondent is to stay away from? Yes No Last four digits of SSN Other Addresses: Contact phone(s): home work cell msg Where is respondent now (what street addr ess)? Other information about respondent: Sex Race *Date of Birth* HT WT Hair Eyes State ID / Driver’s Lic. # ST Other Identifiers (facial hair, piercings, sc ars, tattoos, marks, etc.) Friends / relatives / phone numbers / hangouts: Hazards at respondent’s home (dogs, traps, guns): Describe respondent’s house: log frame apartment single family duplex 1 story 2 story 3+ story main color trim color Garage: separate attached none 4x4 needed to access address? Y N Respondent’s employer Employer address Work phone Work hours Respondent’s position Supervisor Respondent’s vehicle information Make Model Plate No. State Year van pickup canopy camper toolbox car 2 door 4 door SUV other Other vehicles respondent is known to drive: C. OFFICER SAFETY INFORMATION Previous contact with police by respondent? No Yes Explain: Any threats by respondent toward petitioner, family, police? Describe: Weapons accessible to respondent (pistol, rifle, knife, other): Expected mental state or history of re spondent (include alcohol or drug use): Is a divorce or other legal action pending that involv es the respondent (child custody, eviction, bankruptcy, repossession of property)? Draw a map on the back of this form if it will help law enforcement. DV-127 (5/10)(cs) Civil Rule 65.1 CONFIDENTIAL LAW ENFORCEMENT INFORMATION SHEET (DOMESTIC VIOLENCE OR STALKING)