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Petition For Order For Protection And Request For Hearing (Filed On Behalf Of Child) PO-0101 - Indiana
| Petition For Order For Protection And Request For Hearing (Filed On Behalf Of Child) 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. __________________________ ___________________________________________ Name of Minor Child, Petitioner ___________________________________________, By Child's Next Friend, (Your Name) vs. ___________________________________________, Respondent (Person to be Restrained) ) ) ) ) ) ) ) PETITION FOR AN ORDER FOR PROTECTION AND REQUEST FOR A HEARING--Filed on Behalf of a Child 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 a child. The child who needs protection is or has been a victim of domestic or family violence, a sex offense, or stalking, and I am that person's: ___ parent ___ guardian ___ other representative (describe:___________________________ _________________________________________________). What is the Respondent's relationship to the child who needs protection? a. The Respondent is a family or household member (check only the line which best applies): ___ the Respondent is, or used to be my spouse and the child lived with us; ___ the Respondent and I resided together in an intimate relationship and the child lived with us; ___ the Respondent is a parent of the child; ___ the Respondent is, or used to, date the child; ___ the Respondent is, or has been, engaged in a sexual relationship with the child; ___ the Respondent and the child who needs protection have a child in common; ___ the Respondent and the child are related by blood or adoption. The Respondent is the child's _________________________; ___ the Respondent and the child are, or used to be, related by marriage. The Respondent is the child's _________________________; ___ the Respondent is, or used to be, the child's guardian; ___ the Respondent is, or used to be, the child's custodian; ___ the Respondent is, or used to be, the child's foster parent; 1 TCM-PO-0101 Approved 07/02 Rev. by State Ct. Admin. 07/12 American LegalNet, Inc. www.FormsWorkFlow.com 2. b. c. ___ the child who needs protection is a minor child of someone in one of the types of relationships described above. ___the Respondent has committed stalking against the child who needs protection. ___the Respondent has committed a sex offense against the child who needs protection. 3. 4. 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. the child who needs protection lives in this county. _____ d. the Petitioner lives 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. 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 the child who needs protection; ___ the Respondent threatened to cause physical harm to the child who needs protection; ___ the Respondent did cause physical harm to the child who needs protection; ___ the Respondent placed the child who needs protection in fear of physical harm; ___ the Respondent caused the child who needs protection to involuntarily 2 TCM-PO-0101 Approved 07/02 Rev. by State Ct. Admin. 07/12 American LegalNet, Inc. www.FormsWorkFlow.com 7. engage in sexual activity by force, threat of force, or duress; ___ the Respondent committed stalking against the child who needs protection; ___ the Respondent committed a sex offense against the child who needs protection. ___ 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 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
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