South Dakota > Statewide > Protection Orders > Domestic
Petition And Affidavit For A Protection Order (Domestic Petition) UJS-091A - South Dakota
| Petition And Affidavit For A Protection Order (Domestic Petition) Form. This is a South Dakota form and can be used in Domestic Protection Orders Statewide . |
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STATE OF SOUTH DAKOTA COUNTY OF ) ) ) IN CIRCUIT COURT JUDICIAL CIRCUIT Petitioner TPO NO._____________________ -vsPETITION AND AFFIDAVIT FOR A PROTECTION ORDER (DOMESTIC ABUSE) Respondent I, , the above-named Petitioner, or the Parent/Guardian of the minor child Petitioner, being duly sworn upon oath, state and affirm the following: I am a resident of County, South Dakota. The Respondent is a resident of County, South Dakota. The person I am asking the Court to restrain from committing acts of domestic abuse is (check all that apply): a spouse (married); a former spouse (divorced); a person related to me by blood or adoption (specify relationship___________________________); a person who lives with me in the same household (lease or own by petitioner, respondent or both) __________________________________________________________________________________; a person with whom I have lived with in the past; a person with whom I have had a child. I AM ASKING THE COURT FOR A PROTECTION ORDER BASED UPON THE FACTS BELOW: (day) , (year) , at approximately o'clock (am/pm), On or about (month) the person against whom I seek this Protection Order committed the following act(s) of domestic abuse: The person caused me physical harm or bodily injury. The person attempted to cause me physical harm or bodily injury. The person's actions have made me fearful that he/she is about to cause me physical harm or bodily injury. The person violated a protection order. The person willfully, maliciously, and repeatedly followed me. The person harassed me by pursuing a knowing and willful course of conduct which seriously alarms, annoys, or harasses me, with no legitimate purpose. The pattern of conduct is a series of acts over a period of time, however short, showing a continuing pattern of harassment. The person made a credible threat with the intent to place me in a reasonable fear of death or great bodily injury. The person willfully, maliciously, and repeatedly harassed me by means of any verbal, electronic, digital media, mechanical, telegraphic, or written communication. I, as the Petitioner, have been the victim of a crime of violence. 1 Form UJS-091A (Domestic Petition) Rev. 05/08 American LegalNet, Inc. www.FormsWorkflow.com Provide a detailed description of what happened on the above date: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Yes Yes Yes Yes No No No No Don't Know Don't Know Don't Know Don't Know Was law enforcement called? Was the person against whom you seek protection arrested for this incident? Is the person in jail? Has the person violated previous protection orders? If so, against whom________________________________________ Give the date of the violation_______________ and the county and state of the violation Has the person been found guilty of violating previous protection orders? If so, against whom Give the date of the conviction _______________ and the county and state of the conviction Does the person possess guns or weapons? Was a weapon used in this incident? Has the person threatened anyone with a weapon? Yes No Don't Know Yes Yes Yes No No No Don't Know Don't Know Don't Know Provide a detailed description of other similar incidents or actions that the person has committed and reasons you believe it will continue: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 2 Form UJS-091A (Domestic Petition) Rev. 05/08 American LegalNet, Inc. www.FormsWorkflow.com Continued from Page 2 _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ REQUEST FOR HEARING AND PROTECTION ORDER Based upon this Petition and Affidavit in which I truthfully set forth the details of the domestic abuse, I respectfully ask the Court to set a date to hear this matter and after hearing the evidence, to grant me a Protection Order: 1) To Restrain the Respondent from acts of abuse and physical harm, making threats of abuse, stalking or harassment. 2) To Grant the Protection Order for a period of time (no longer than 5 years). 3) To exclude the Respondent from the Petitioner's residence listed in 4C. 4) To Order that the Respondent shall not come within a distance of ___________ from the following persons and places: A. The Petitioner personally B. The following minor children named as othe
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