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Petition For Order For Protection And Request For Hearing (Filed By Person Seeking Protection) PO-0100 - Indiana
| Petition For Order For Protection And Request For Hearing (Filed By Person Seeking Protection) Form. This is a Indiana form and can be used in Protection Order Protective Order Statewide . |
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STATE OF INDIANA ) ) SS: COUNTY OF ___________ ) IN THE ______________ COURT_____ (____________DIVISION, ROOM ____) CASE NO. __________________________ ________________________________________, Petitioner (Your Name) vs. ________________________________________, Respondent (Person to be Restrained) ) ) ) ) ) PETITION FOR AN ORDER FOR PROTECTION AND REQUEST FOR A HEARING--Filed by Person Seeking Protection IMPORTANT: This is a public document and a copy of it will be placed in the Court's file. A copy may also be sent to the Respondent. (Check those which apply) 1. I am filing this Petition for myself: ___a. I am or have been a victim of domestic or family violence; ___b. I am or have been a victim of a sex offense; ___c. I am or have been a victim of stalking. 2. The Respondent's relationship to me is: a. the Respondent is my family or household member (check only the line which best applies): ___ the Respondent is, or used to be, my spouse; ___ the Respondent and I resided together in an intimate relationship; ___ the Respondent and I have a child in common; ___ the Respondent and I are dating, or have dated, each other; ___ the Respondent and I are, or have been, engaged in a sexual relationship; ___ the Respondent and I are related by blood or adoption. The Respondent is my _________________________; ___ the Respondent and I are, or used to be, related by marriage. The Respondent is my _________________________; ___ the Respondent is, or used to be, my guardian; ___ the Respondent is, or used to be, my ward; ___ the Respondent is, or used to be, my custodian; ___ the Respondent is, or used to be, my foster parent; or, ___ I am a minor child of a person in one of the types of relationships described above. ___ I have adopted the child of the respondent. ___the Respondent has committed stalking against me. 1 TCM-PO-0100 Approved 07/02 Rev. by State Ct. Admin. 07/12 American LegalNet, Inc. www.FormsWorkFlow.com b. c. 3. 4. ___the Respondent has committed a sex offense against me. How old is the Respondent? ________ years old. Please list all cases (divorce, protection orders, paternity, guardianship, criminal, juvenile, civil) involving the Respondent, yourself, or a child you have with the Respondent (attach additional sheets of paper if necessary): Case Name Case Number County & State __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ _____ Continued on Attachment 4a. 5. This case is filed in this county because: _____ a. the Respondent lives in this county. _____ b. the incident(s) of domestic or family violence, stalking, or the sex offense happened in this county. _____ c. I live in this county. 6. If you are not represented by an attorney, fill in your public mailing address: __________________________________________________________________ __________________________________________________________________ This address will not be kept secret, so you should use a mailing address that you feel comfortable having public. The address you place on the Confidential Form, PO-0104 will be kept confidential. If the order has been granted by the court, you may be eligible to obtain a confidential address through the Attorney General's Address Confidentiality Program (ACP). Call the ACP at: 1-800-321-1907 to get information on how to participate in that program. The Respondent has committed the following act(s) of domestic or family violence, stalking, or a sex offense (check those which apply): ___ the Respondent attempted to cause physical harm to me; ___ the Respondent threatened to cause physical harm to me; ___ the Respondent did cause physical harm to me; ___ the Respondent placed me in fear of physical harm; ___ the Respondent caused me to involuntarily engage in sexual activity by force, threat of force, or duress; ___ the Respondent committed stalking against me; ___ the Respondent committed a sex offense against me; ___ the Respondent committed an act of animal cruelty by beating, torturing, mutilating, or killing a vertebrate animal without justification with an intent to threaten, intimidate, coerce, harass or terrorize a family or household 2 TCM-PO-0100 Approved 07/02 Rev. by State Ct. Admin. 07/12 American LegalNet, Inc. www.FormsWorkFlow.com 7. member. 8. Describe what happened in each of the above incidents including the date(s), place(s) and witnesses to each incident (attach additional sheets of paper if necessary): Date of Incident #1: ______________ Place of Incident: __________________________________________________ Description of Incident: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ List the names of all of the people who were present during the incident. You must include your own name if you were present: _______________________________________________________________________________ _____________________________________________________ Date of Incident #2: ______________ Place of Incident: __________________________ Description of Incident: _______________________________________________________________________________ _______________________________________________________________________________ ________________________________________ List the names of all of the people who were present during the incident. You must include your own name if you were present: __________________________________________________________________ __________________________________________________________________ Date of Incident #3: ______________ Place of Incident: __________________________ Description of Incident: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ List the names of all of the people who were present during the incident. You must include your own name if you were present: __________________________________________________________________ __________________________________________________________________ _____ Continued on Attachment 8a. 9. I am asking the Court to order the
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