“Petition for Order of Protection Case No

Petitioner’s home address: Petitioner Date of Birth Respondent Date of Birth, if known vs

Petitioner’s work address: Respondent’s home address: Respondent’s work address: at least 18 years of age I am the petitioner and I am filing on behalf of myself

I am filing on behalf of a family or household member who is: a minor(s): (list) an adjudicated incompetent person: (list) The respondent is I am an employee or volunteer of a domestic violence shelter or program, and I am filing on behalf of a minor

under 18 but emancipated

under 18 but emancipated

at least 18 years of age The respondent and petitioner (or victim if filing on behalf of a minor or incompetent person): (check all that apply) Are spouses; Are parent and child; Are former spouses; Have or have had a child in common; or If order of protection of children is requested: Are related by blood; Currently reside together or cohabit; Formerly resided together or cohabited; Are presently or in the past have been in a dat- ing relationship

Children Date of Birth Address Relationship to Parties The respondent has committed domestic abuse to the petitioner or victim by the following acts: (describe) I am afraid of the respondent and: (describe) (1) There is an immediate and present danger of domestic abuse to me; or (2) The respondent is scheduled to be released from incarceration within thirty (30) days and upon the respondent’s release there will be an immediate and present danger of domestic abuse to me

The reasons are as follows: (describe) Petitioner requests that the court issue an ex parte order of protection with the following provisions: (check all that apply) Excluding the respondent from a shared residence or from the residence of the petitioner or victim. Address of residence: Excluding the respondent from the place of business, employment, school, or other location of the petitioner or victim. Address of residence: Excluding the respondent from the place of business, employment, school, or other location of the petitioner or victim. Address of: Place of business: Employment: School: Other (identify): Prohibiting the respondent, directly or through an agent, from contacting the petitioner or victim, except under the following conditions: Awarding temporary custody of minor children as follows: Child’s Name and Name of Person to Receive Custody Requiring the respondent to pay child support in the amount of $ Requiring the respondent to pay spousal support in the amount of $ Excluding the petitioner’s address from notice to the respondent per child per month per month It is further requested that upon hearing, the court issue a full order of protection with the following provisions: (check all that apply) Excluding the respondent from the shared residence or from the residence of the petitioner or victim. Address of the residence: Excluding the respondent from the place of business, employment, school, or other location of the petitioner or victim. Address of: Place of business: Employment: School: Other (identify): Awarding temporary custody of minor children as follows: Child’s Name and Name of Person to Receive Custody Requiring the respondent to pay child support in the amount of $ per child per month Requiring the respondent to pay spousal support in the amount of $ Requiring the respondent to pay filing fees, service fees, court costs and petitioner’s attorney fees

I am involved in pending litigation with the respondent in the case of: per month Case No.: Circuit or District Judge: County or City: I have previously filed a petition for an order of protection against the respondent in the following case or cases: Case No.: Circuit Judge: County: 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 Subscribed and sworn to before me this day of , 20

Notary Public My Commission Expires: ”