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Petition For Order Of Protection - Arkansas

Petition For Order Of Protection Form. This is a Arkansas form and can be used in Circuit Court Benton Local County .
 Fillable pdf Last Modified 9/27/2006
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IN THE CIRCUIT COURT OF BENTON COUNTY, ARKANSAS 1. Petitioner Date of Birth Petitioner's Workplace and Address: 2. Petitioner's Home Address: VS: 3. Respondent Date of Birth Case No.: 4. Respondent's Home Address: Respondent's Workplace and Address: PETITION FOR ORDER OF PROTECTION 5. _____ I am the Petitioner and am (a) _____ at least 18 years of age; (or)(b) _____ under 18, but emancipated. 6. _____ I am filing on behalf of myself. 7. _____ I am filing on behalf of a family or household member who is: _____ a minor: (full names) _____ an adjudicated incompetent person: (name) 8. _____ The Respondent is: (a) _____ at least 18 years of age; or (b) _____ under 18, but emancipated. 9. The Respondent and Petitioner (or Victim, if filing on behalf of a minor or incompetent person): (Check One) _____ are spouses/date of separation __________ _____ are blood relatives _____ are parent and child _____ currently reside together or cohabitate _____ are former spouses _____ child in common _____ are/were in a dating relationship _____ formerly resided together or cohabitated/date of separation __________ 10. If Order of Protection of children is requested: NAMES OF CHILDREN DATE OF BIRTH ADDRESS RELATIONSHIP TO PET/RES. American LegalNet, Inc. www.USCourtForms.com 11. The Respondent has committed domestic abuse to the Petitioner or Victim by the following acts(s): (briefly describe with date(s) of incident(s): _______________________________________________________________________________________________ _______________________________________________________________________________________________ ______________________________________________________________________________________________. 12. ___1. I am afraid of the Respondent and there is an immediate and present danger of domestic abuse to me because: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ ___2. The Respondent is scheduled to be released from incarceration within 30 days and upon the Respondent's release, there will be an immediate and present danger of domestic abuse to me. The reason(s) are as follows: _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 13. ___ Petitioner requests that the court issue an Ex Parte Order of Protection with the following provisions: (Check all that apply) (a) __ Excluding the Respondent from a shared residence or from the residence of the Petitioner or Victim. Address of Residence: _________________________________________________________________________ (b) __ Excluding the Respondent from the place of business, employment, school, or other locations of the Petitioner or Victim. Address of: Employment Address: _________________________________________________________________________ School Address: ______________________________________________________________________________ Other: ______________________________________________________________________________________ (c) __Awarding temporary custody of the minor children of the Petitioner and Respondent as follows: Child's Name Person to receive custody (d) ___ Excluding the Petitioner's address from Notice to the Respondent. (e) Civil Standby Requested? Yes___ No ___. For Petitioner or Respondent? _______________________ Address where Civil Standby is needed: ___________________________________________________________ 14. It is further requested that upon hearing, the court issue a full Order of Protection with the following provisions: (Check all that apply) (a) ____Excluding the Respondent from a shared residence or from the residence of the Petitioner or Victim. Address of residence: ____________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com (b) ___ Excluding the Respondent from the place of business, employment, school, or other location of the Petitioner or Victim. Addresses of: Employment address: ___________________________________________________________________ School address: ________________________________________________________________________ Other: ________________________________________________________________________________ (c) ___ Awarding custody of the minor children as follows: Child's Name Person to receive custody (d) If visitation is allowed, name, address, and phone number of third party to provide transportation: Name: _________________________________________________________________________ Address: ________________________________________________________________________ Phone Number: (_______) __________________________________________________________ 15. Is there a pending divorce action between the parties _____________? If yes, give Case Number: ________________ Petitioner's Attorney: ___________________________ Respondent's Attorney: _____________________________ 16. The Petitioner, under oath, states that the facts stated in the above petition are true according to the Petitioner's best knowledge and belief. __________________________________ Date _____________________________________________________ Petitioner's Signature STATE OF ARKANSAS COUNTY OF BENTON Subscribed and sworn to me this ______________ day of _________________, 200___. Brenda DeShields ________________________ Circuit Clerk _____________________________ Deputy Clerk Petitioner hereby agrees and acknowledges that he/she will be present in Court at the time set for a hearing on this matter to give testimony. If you do not show up for your court date, you may be charged $190.00. ___________________________________ Petitioner's Signature American LegalNet, Inc. www.USCourtForms.com AFFIDAVIT OF DOMESTIC ABUSE (To be used if Temporary Order is requested.) 1. PREVIOUS HISTORY: (INCLUDING DATES) of domestic abuse between Petitioner and Respondent which includes: Physical harm, bodily injury, assault, or the infliction of fear of imminent physical harm, bodily injury, or assault, or any sexual conduct which would constitute a crime in the state of Arkansas. 2. Existence of IMMEDIATE DANGER to your person or members of
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