THIRD JUDICIAL DISTRICT,
STATE OF IDAHO
COUNTY OF OWYHEE
_________________________________________
)
______________________________________, ) Case No. CV-______________
Petitioner, )
-vs- ) SWORN
APPLICATION FOR
) PROTECTION
ORDER
______________________________________, )
Respondent. )
_________________________________________ )
THE LAW REQUIRES THAT A COPY OF THIS COMPLETED FORM
BE GIVEN TO THE RESPONDENT.
1.
I want a protection order against _________________________________,
and my relationship to that person is: (check all those that apply)
¨ We are married. How long?
______________________
¨ We are divorced.
Date__________________________________, _________
County_________________________
¨ A divorce has been filed. County___________________________
Case No. ________________________
¨ We are related by blood or marriage. (check
one of the following)
¨ spouse ¨
father/mother/child ¨ brother/sister ¨ grandparent
¨ other:__________________________________________________________
¨ We reside together.
¨ We lived together from
_____________________________, _________ to
____________________________, ________.
¨ We are parents of a child(ren)
together.
¨ I am seeking this order on
behalf of a minor child who is in a
dating relationship with the Respondent. I am the minor’s
¨ custodial parent ¨
non-custodial parent ¨ guardian.
Please describe the dating
relationship, including the nature of
the relationship, the length of time
the relationship has existed,
the frequency of interaction, and the
time since the relationship
ended, if applicable.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
_________________________________________________________________.
Age of Respondent _________
SWORN APPLICATION FOR
2. ¨ I live, or am staying, in this county. Respondent lives in
__________________________ County.
¨ We share a ¨ rental unit ¨ own a home together at Street
Address and
Town:________________________________________________
3. ¨ I have left the residence. ¨ I want to return to ¨
live. ¨
get
personal
belongings. ¨ other:__________________________________.
4. ¨ A
business is run from the home.
Type of business:_____________________ Run by:__________________
5. ¨ I am the natural/adoptive parent or legal guardian
of the
following child(ren):
Person with Whom County and State
Child
Has Lived Where Child Has Lived
Relationship
Name of Child Age For Last 6 Months For Last 6 Months to Respondent
______________ ___ ___________________
_____________________ _____________
______________ ___
___________________ _____________________ _____________
______________ ___
___________________ _____________________ _____________
______________ ___
___________________ _____________________ _____________
______________ ___
___________________ _____________________ _____________
6. ¨ I want custody of all of the above child(ren),
except:
___________________________________________________________________.
7. ¨ There is a custody order affecting a child(ren) of
mine and the
Respondent. County and
State_________________________
Year________
Case No.______________________
8. ¨ There are or have been child protection, adoption,
or
guardianship proceedings affecting my child(ren) or the
Respondent’s
child(ren). ¨ Now Pending ¨ Case Closed
County and State_________________________________ Year_________
Case No.______________________
9. ¨ I have applied for a
protection order before.
County____________________
Date____________________
Against Whom______________________
¨ The Respondent has applied for a protection
order before.
County__________________
Date____________________
Against Whom______________________
10. I want a protection order now because I am afraid the
Respondent will
physically injure, sexually abuse, or imprison me or a member of my family
or household. (Please tell
what happened, the dates, who did what to whom,
whether a weapon was
involved, if the police were contacted, and describe
any injuries. Also, briefly
describe any other recent incidents of domestic
violence.)
SWORN APPLICATION FOR
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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___________________________________________________________________________
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ON BACK OF THIS PAGE.
11. ¨ The Respondent has been involved in crimes involving violence,
child
abuse, weapons, drugs, or alcohol. Please describe. (What, when, and
where? Were charges filed?)
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________.
12. ¨ The Petitioner has been involved in crimes involving
violence,
child abuse, weapons, drugs, or alcohol. Please describe. (What, when, and
where? Were charges filed?)
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________.
SWORN APPLICATION FOR
I ASK THE COURT TO ORDER THE FOLLOWING:
1. ¨ That the Respondent shall
not contact, molest, attack, strike,
threaten, sexually assault, batter, telephone, follow, harass, or otherwise
disturb the peace of the Petitioner and minor child(ren) residing in the
household. ¨ and others:________________________________________________.
2. ¨ That the Respondent shall at all times stay away
from:
¨ NO ADDRESS GIVEN BECAUSE I DO NOT WANT MY ADDRESS ON THE
PETITION.
¨ my residence at
_________________________________________________.
¨ my work place at
________________________________________________.
¨ my child(ren)’s school and child care at
_________________________
_________________________________________________________________.
¨ other:___________________________________________________________.
3. ¨ That the Respondent
move from the residence at ___________________
_____________________ and take only tools or items of employment, necessary
personal clothing, and personal
effects (peace officer’s discretion) from
the dwelling.
4. ¨ That the custody of minor
child(ren) named in Section 5 above be
awarded to ¨ me ¨ Respondent with the other parent having:
¨ visitation as follows (list
specific days and times):__________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
¨ supervised visitation, why
and by whom: _______________________
__________________________________________________________________
¨ neutral drop-off and
pick-up location.
¨ no visitation.
¨ That the custody of
minor child(ren) named in Section 5 above be
awarded to the Respondent.
5. ¨ That the Respondent be
ordered to participate in treatment or
counseling.
6. ¨ Other relief
requested:___________________________________________
___________________________________________________________________________
__________________________________________________________________________.
I CERTIFY UNDER OATH THAT I HAVE
READ THIS APPLICATION, OR HAVE HAD
IT READ TO ME, AND THAT THE FACTS
STATED IN THIS APPLICATION ARE TRUE.
INTENTIONALLY PROVIDING FALSE
INFORMATION IS A CRIME.
Dated:
___________________________ Signed:
____________________________
Petitioner
Subscribed and sworn to
before me this ____ day of ________________, 200__.
CLERK OF THE DISTRICT COURT
_______________________,Deputy Clerk
SWORN APPLICATION FOR