Connecticut > Statewide > Family
Application For Relief From Abuse JD-FM-137 - Connecticut
| Application For Relief From Abuse Form. This is a Connecticut form and can be used in Family Statewide . |
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APPLICATION FOR RELIEF FROM ABUSE JD-FM-137 Rev. 10-12 C.G.S. ยงยง 29-28, 29-32, 29-33, 46b-15, 52-231a, PA 12-114; June 12 Spec. Sess. PA 12-2 Secs. 97, 98 STATE OF CONNECTICUT ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. SUPERIOR COURT www.jud.ct.gov Instructions To Person Filing Application (Applicant) { 1. Use a typewriter, print clearly in ink, or fill out on-line. You must also fill out an Affidavit, form JD FM-138. Give both forms to the Clerk of Court. 2. After your Application and Affidavit are processed, the clerk will give you the proper papers to have served on the Respondent. 3. Make sure the originals are returned to court after service. Instructions To Clerk Judicial District of { 1. If Ex Parte relief is ordered, prepare the following forms: Order of Protection, form JD-CL-99, and if applicable, Additional Orders of Protection, form JD-CL-100; Order and Notice of Court Hearing, form JD-FM-140; General Restraining Order Notifications (Family), form JD-CL-104. 2. If Ex Parte relief is NOT ordered, prepare the following forms: Order and Notice of Court Hearing, form JD-FM-140; Information Concerning Firearms in Relief From Abuse Cases, form JD-CL-104A. 3. Provide the Applicant with the original and one copy of the Application and Affidavit. Retain copies of each for court file. 4. Provide the Applicant with the Procedures For Relief From Abuse Process brochure JDP-FM-142 for further information. Court location (number, street, town, zip code) Docket number Name of applicant (Last, first, middle initial) Date of birth (mm/dd/yyyy) Sex (M/F) Race Address to which mail is to be sent (Number, street)* (See NOTE below) Home/residence address* (See NOTE below) (Town) (State) (Zip Code) Same as mailing address (Town) (State) (Zip Code) Work address* (See NOTE below) (Town) (State) (Zip Code) *NOTE: The address or addresses you provide will be included on papers that are in the court file and will be provided to the respondent. The address or addresses you provide will also determine which law enforcement agencies are notified if a restraining order is issued. If you believe that giving out your home or work or school address would put you and/or your children's health, safety or liberty in danger, you may use a mailing address that is different from your home or work address. You can also file a Request for Nondisclosure of Location Information form (JD-FM-188) with the Clerk of Court. If you provide a mailing address that is different from your home address or work address, and you do not provide a home or work or school address, the protection you receive from the restraining order may be limited. Information About The Respondent Name of respondent (Person the application is filed against) (Last, first, middle initial) Date of birth (mm/dd/yyyy) Sex (M/F) Race Address of respondent (Number, street) (Town) (State) (Zip Code) Respondent's telephone number Other identifiers (Examples include height, weight and approximate age) Respondent is ("X" all that apply) My spouse or a person I have a civil union with My former spouse or a person I had a civil union with Parent of my child My parent My child Someone I have cohabited with as an intimate partner (romantic, spousal, or sexual relationship while living together) A person related to me by blood or marriage A person I reside or resided with A caretaker who is providing shelter in his or her residence to a person 60 years of age or older A person I have (or recently had) a dating relationship with "X" here if a Protective Order or Restraining Order exists affecting any party to this Application (Enter docket number and court location) Docket number Court location "X" here if a dissolution of marriage (divorce), dissolution of civil union, custody or visitation action exists involving the same parties. (Enter docket number and court location) Docket number Court location Page 1 of 2 (continued on page 2) American LegalNet, Inc. www.FormsWorkFlow.com Name of applicant Name of respondent Docket number Application For Relief From Abuse I have been subjected to a continuous threat of present physical pain or physical injury, stalking or a pattern of threatening, by the Respondent named above as explained more fully in my attached Affidavit. 1. I request that the court order the following conditions: ("X" all that apply) CT01 CT03 CT05 The Respondent not assault, threaten, abuse, harass, follow, interfere with, or stalk me. (CT01) The Respondent stay away from my home or wherever I shall reside. (CT03) The Respondent not contact me in any manner, including by written, electronic or telephone contact, and not contact my home, workplace or others with whom the contact would be likely to cause annoyance or alarm to me. (CT05) The Respondent may return to the home one time with police to retrieve belongings. (CT14) The Respondent stay 100 yards away from me. (CT16) That the order protect my minor children. (CT19) Name (Last, first, middle initial) Sex (M/F) Date of birth (mm/dd/yyyy) Name (Last, first, middle initial) Sex (M/F) Date of birth (mm/dd/yyyy) CT14 CT16 CT19 1 2 3 CT31 4 5 6 That the order protect animals owned or kept by me. (CT31) 2. I request that the court make the following temporary child custody and visitation orders: CT20 Award me temporary custody of the following minor child(ren) who is (are) also the child(ren) of the Respondent. Name (Last, first, middle initial) Sex (M/F) Date of birth (mm/dd/yyyy) Name (Last, first, middle initial) Sex (M/F) Date of birth (mm/dd/yyyy) 1 2 3 CT21 4 5 6 With visitation as follows: CT22 Without visitation rights to the Respondent. 3. I request that the court order the following: (further order) 4. I am in school and I request that a copy of the restraining order, if it is granted, be sent to my school Name of school Fax number of school Address of school (Number, street) (Town) (State) (Zip code) Request For Ex Parte (Immediate) Relief ("X" if this applies) 5. I request that the court order Ex Parte (immediate) relief because I believe there is an immediate and present physical danger to me and / or my minor children and / or animals owned or kept by me. Date signed Signed (Applicant) Signed (Clerk, Notary, Commisioner of Superior Court) Subscribed and X sworn to befo
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