III. Explain The Abuse That Has Happened:
(Begin With The Most Current Act. You May Add Additional 8" x II" Sheets of Paper If Necessary):
Date and location of the abuse:__________________________________________________________________________.
Describe how the defendant hurt or threatened you, a minor, or a person for whom you are applying: ____________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
I am in fear of further abuse by the defendant because: _______________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
IV. Legal Information Required (check all that apply):
I, or the abused party for whom I am applying, have a current restraining order against the defendant:
YES NO. If YES, the county and state where it was issued: _________________________________________________.
Defendant has a current restraining order against me or the person for whom I am applying:
YES NO. If YES, The county and state where it was issued: ________________________________________________.
There are other legal actions filed between and defendant and me or the person for who I am applying (divorce, legal separation, annulment, modification of custody of visitation, criminal charges from the alleged abuse):
YES NO. If YES. In what county and state was it filed: ____________________________________________________.
V. Children
The children of defendant and me, who are under 19 years old and have been living in my household:
Name:_____________________________________________________________________Age:____________________
Name:_____________________________________________________________________Age:____________________
Name:_____________________________________________________________________Age:____________________
Name:_____________________________________________________________________Age:____________________
B. Is there a custody order concerning any of these children? YES NO
C. For the last six months, the children have lived (in what state and with whom):
Child:_______________________________Lived with:__________________________________State:_______________
Child:_______________________________Lived with:__________________________________State:_______________
Child:_______________________________Lived with:__________________________________State:_______________
Child:_______________________________Lived with:__________________________________State:_______________
VI. Filing fees: I wish to be considered for a waiver of filing fees due to indigency. My Affidavit of Substantial Hardship, (Form C-10) is attached.
I receive: Aid to Dependent Children (ADC) Food Stamps Supplemental Security Income (SSI)
VII. Residence
DEFENDANT MAY BE REQUIRED TO MOVE FROM THE PLAINTIFF'S RESIDENCE, IF THE RESIDENCE IS IN THE SOLE NAME OF THE PLAINTIFF, IF IT IS JOINTLY OWNED OR RENTED BY THE PLAINTIFF AND THE DEFENDANT, OR IF THE PARTIES ARE MARRIED TO EACH OTHER.
Residence is owned leased/rented by: ________________________________________________________________
Plaintiff must notify the court of any change in address.
VIII. Ex Parte Relief Requested:
Plaintiff asks that the relief requested (as marked by me) and such other relief as the court thinks proper, be granted:
Enjoin the defendant from threatening to commit or committing any further act of abuse as defined in §30-5-2(a)(1).
Prohibit the defendant from harassing, annoying, telephoning, contacting, or otherwise communicating, directly or indirectly, with the plaintiff or minor children.
Order the defendant to stay away from the residence, school, or place of employment of the plaintiff or minor children, or any specified place frequented by the plaintiff, the minor children, or any designated family member which the defendant has no legitimate reason to frequent.
Name and location of any other specified place(s):____________________________________, |