AIB: AR Law/ 9-15-203. Petition

Arkansas Law

9-15-203. Petition - Form.

(a) The clerks of the court shall provide simplified forms and clerical assistance to help petitioners with the writing and filing of a petition under this chapter if the petitioner is not represented by counsel.

(b) The petition may be in substantially the following form:

Petition for Order of Protection

Case No. __________

__________________ Petitioner's home address:

Petitioner

______________________________________________________________________

__________________ ___________________________________________________

Social Security Number

Petitioner's work address:

vs.

______________________________________________________________________

__________________ Respondent's home address:

Respondent

______________________________________________________________________

__________________

Social Security Number,

if known

Respondent's work address:

______________________________________________________________________

________________________________________________________________

_ I am the petitioner and _ at least 18 years of age _ under 18 but emancipated.

_ 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 _ at least 18 years of age _ under 18 but emancipated.

The respondent and petitioner (or victim if filing on behalf of a minor or incompetent person): (check all that apply)

_ are spouses _ are related by blood

_ are parent and child _ currently reside together or

cohabitate

_ are former spouses _ formerly resided together or

cohabitated

If order of protection of children is requested:

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 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 $________ per month

_ excluding the petitioner's address from notice to the respondent

_ 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 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 $________ per month

_ requiring the respondent to pay filing fees, service fees, court costs and petitioner's attorney fees.

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 ____________, 19____.

____________________________________________________________________

Notary Public

My Commission Expires:

____________________________________

History. Acts 1991, No. 266, § 3; 1999, No. 662, § 1.