STATE OF INDIANA ) IN THE ______________
COURT_____
) SS: (____________DIVISION, ROOM ____
)
COUNTY OF ___marion________)
CASE NO. __________________________
________robbin
stewart________________________________, )
Petitioner (Your Name) )
vs. )
____devin baker________________________________, )
Respondent (Person to be
Restrained) )
PETITION
FOR AN ORDER FOR PROTECTION AND REQUEST FOR A HEARING—Filed by
Person Seeking Protection
IMPORTANT: This is a public document and a copy of it
will be placed in the Court’s file. A copy may also be sent to the
Respondent.
(Check those which apply)
1.I am filing this Petition for myself:
__x_c.
I am or have been a victim of stalking;
x
d. I am or have been a victim of repeated acts of harassment.
2.The Respondent’s relationship to me is:
If
Respondent is not a family or household member as indicated above,
but Respondent has committed stalking, a sex offense, or repeated
acts of harassment (check only the line below which best applies):
__x
_the Respondent has committed stalking against me.
___the
Respondent has committed a sex offense against me.
X
___the Respondent has committed repeated acts of harassment against
me.
3.How old is the Respondent? ________ years old.
4.Please list all cases (divorce, protection
orders, paternity, guardianship, criminal, juvenile, civil, military
protection orders) involving the Respondent, yourself, or a child you
have with the Respondent (attach additional sheets of paper if
necessary):
Case
Name Case Number County & State
____________________________________________________________________dog
bite
case________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
_____
Continued on Attachment 4a.
_________________________________________________________________
5.This case is filed in this county because:
_____ a.
the Respondent lives in this county.
_x____ b.
the incident(s) of domestic or family violence, stalking, sex
offense,
or harassment happened in this county.
__x___ c.
I live in this county.
6. If
you are not represented by an attorney, fill in your public mailing
address:
___p o 4015 e washington
st__________46201_______________________________________________________________________________________________________________________This
address will not be kept secret, so you should use a mailing address
that you feel comfortable having public. The address you place on the
Confidential Form, PO-0104 will be kept confidential. If the Court
grants the order, you may be eligible to obtain a confidential
address through the Attorney General’s Address Confidentiality
Program (ACP). Email the ACP at: confidential@atg.state.in.us
to get information on how to participate in that program.
The Respondent has committed the following
act(s) of domestic or family
violence,
stalking, sex offense, or harassment (check
those which apply):
___
the Respondent attempted to cause physical harm to me;
__x_
the Respondent threatened to cause physical harm to me;
___
the Respondent did cause physical harm to me;
__x_
the Respondent placed me in fear of physical harm;
___
the Respondent caused me to involuntarily engage in sexual activity
by
force,
threat of force, or duress;
__x_
the Respondent committed stalking against me;
___
the Respondent committed a sex offense against me;
_?__
the Respondent committed an act of animal cruelty by beating,
torturing,
mutilating,
or killing a vertebrate animal without justification with an intent
to
threaten, intimidate, coerce, harass or terrorize a family or
household
member;
__x_
the Respondent committed repeated acts of harassment against me.
6.Describe what happened in each of the above
incidents including the date(s),
place(s) and
witnesses to each incident (attach additional sheets of paper if
necessary):
Date of Incident #1: _____day
before dog ticket_________
Place of Incident:
___4015_______________________________________________
Description of Incident:
________He demanded $100. I refused to pay,
He went inside got a gun, displayed his gun, demanded $100 again. I
had a couple of my boys back me up.
______________________________________________________________________________________________________________________________________________________________________________________________
List the names of all of the people who were present
during the incident. You
must include your own name if you were present:
_______me devin batman
dusty______________________________________________________________________________________________________________________________________________________
Date of Incident #2:
______________
Place of Incident:
__________________________
Description of Incident:
___numerous times oh him hassling my dog or me, recently has been
threatening :citizens
arrest”.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
List the names of all of the people who were present
during the incident. You
must include your own name if you were present:
__________________________________________________________________
__________________________________________________________________
____________________________
__________________________________________________________________
_____ Continued on Attachment 8a.
7.I am asking the Court to order the following
relief (check all which apply):
NOTE: The following requested relief may be
granted immediately by the Judge without a hearing. However, if the
petition is based on harassment alone, the relief may be granted ONLY
after notice to the Respondent and after a hearing to be held within
thirty (30) days.
_x__ Prohibit the Respondent from committing, or
threatening to commit, acts of
domestic or family violence, stalking, or sex
offenses against me;
__x_ Prohibit the Respondent from committing, or
threatening to commit, acts of
domestic or family violence, stalking, or sex
offenses against my family or
household members, whose names are:
_kenny, dawn, dustin, sherry,
chico.__________________________________________________________
__________________________________________________________;
___ Prohibit a Respondent from using a tracking device
(as defined in Ind. Code § 35-31.5-2-337.5) to determine the
location of: (a) the Petitioner or property owned by the Petitioner;
and (b) any other family or household member or property owned or
used by the family or household member.
x___ Prohibit the Respondent from harassing, annoying,
telephoning, contacting,
or directly or indirectly communicating with me;
_x__Order the Respondent to stay away from my residence,
school, place of
employment, or other place, which is the ___________,
located at:
_______4015______________________________________________________;
__ Order that this Order of Protection be effective
indefinitely as authorized by I.C. 34-26-5-9, because I was the
victim of the sex or violent offense committed by the Respondent as
described herein, and for which the Respondent is a sex or violent
offender, who is required to register as a lifetime sex or violent
offender.
___Order the Respondent to stay away from the following
location(s) frequented
by my family or household member(s), which may
include a residence,
school, or place of employment: ____4000 block e
washington st______________________________
_____________________________________________________________
_____________________________________________________________.
Please complete:
Please list all owners or lease signers at my residence:
_____________________
__self_______________________________________________________________
_________________________________________________________________.
NOTE: The following requested relief may be
granted immediately by the Judge, but the Court must hold a hearing
within thirty (30) days. If the petition is based on harassment
alone, the relief may be granted ONLY
after notice to the Respondent and after a hearing to be held within
thirty (30) days.
___ Evict the Respondent from my residence, which is
located at:
_____________________________________________________________;
___ Order the Respondent to give me the possession and
use of the following:
___The residence located at:
______________________________________;
___An automobile/other motor vehicle described
as: ___________________
__________________________________________________________;
___ Other necessary personal items,
described as: _____________________
__________________________________________________________
__________________________________________________________;
__x_ Prohibit Respondent from removing, transferring,
injuring, concealing, harming, attacking, mistreating, threatening to
harm, or otherwise disposing of the animal(s) listed below.
Example Name: Max
Age/Type: 9 year old dog
Size /Breed: Large 55 pound black lab
Color/Description: Black hair, pink collar
Animal 1
Name: _chico_____________________________
Age/Type: __2 yrs?____________________________
Size/Breed: ___pit mix___________________________
Color/Description: ______________________________
Animal 2 Name:
______________________________
Age/Type: ______________________________
Size/Breed: ______________________________
Color/Description: ______________________________
Additional animals listed on Attachment 9(a).
__x_ Order that I will have
the exclusive possession, care, custody, or control of an animal(s)
owned, possessed, kept, or cared for by myself, the Respondent, a
minor child of myself or the Respondent, or any other family or
household member listed below.
Animal 1 Name: _chico_____________________________
Age/Type: ______________________________
Size/Breed: ______________________________
Color/Description: ______________________________
___Order the following
additional relief necessary to provide for my safety and
welfare and the safety and welfare of my family or
household members:
______________________________________________________________
felon in possession of a
gun___________________________________________________________
______________________________________________________________
______________________________________________________________.
NOTE: The following requested relief may be
granted ONLY
after notice to the Respondent and after a hearing to be held within
thirty (30) days:
___ Specify the arrangements for parenting time with our
minor child(ren);
___ Require that parenting time be supervised by a third
party;
___ Deny the Respondent parenting time;
__x_ Order the Respondent to pay my attorney fees;
___ Order the Respondent to pay rent for my residence;
___ Order the Respondent to make payment on a mortgage
for my residence;
___ Order the Respondent to pay child support for our
minor child(ren);
___ Order the Respondent to pay support/maintenance for
me;
__x_ Order the Respondent to reimburse me for expenses
related
to the domestic or family violence, stalking, sex
offense, or harassment as follows:
(specify the amount for each expense and bring
documentation of the
expense with you to Court for the Hearing):
___ Medical expenses: $_________________
___ Counseling: $___8______________
___ Shelter: $_________________
___ Repair or replacement of
damaged property: $_________________
___ Other costs or fees I have
as a result of bringing
this case: $__legal fees as yet unknown, est, $1000._______________
__x_ Prohibit the Respondent from using or possessing a
firearm, ammunition, or
deadly weapon;
_x__ Order the Respondent to surrender the following
firearm(s), ammunition, or
deadly weapon(s) to a specified law enforcement
agency (list
each item
below and attach an additional sheet of
paper if necessary):
____________________________________
____pistol. Unknwn make or
model________________________________
____________________________________
____________________________________;
_____
Continued on Attachment 9(b).
______________________________
Additional telephone numbers listed on Attachment
9(c)
By filing this
Petition, I am respectfully requesting that the Court immediately
issue an Ex Parte Order for Protection. I understand that, if I have
asked the Court for any of the following:
evicting the Respondent from
my/our home;
giving me the possession of
personal property;
giving me possession of an
animal;
prohibiting Respondent from
taking action against an animal;
establishing rules for child
parenting time;
requiring the Respondent to
pay fees, expenses, or child support;
forbidding the Respondent
from possessing a firearm, ammunition, or a deadly weapon;
ordering the Respondent to
surrender firearm(s), ammunition, or deadly weapons, or,
allowing me or a child to
continue to use a telephone number for which I will be financially
responsible;
I must also ask the Court to
set a date for a Hearing within thirty (30) days of today’s date.
I understand that if my
petition is based on harassment alone, the Court may grant relief
ONLY after notice to the Respondent and
after a hearing to be held within thirty (30) days.
I understand that if a
Hearing is set, and if I fail to appear for the Hearing, the Court
may terminate the Ex Parte Order and/or dismiss the case.
I affirm, under the penalties for perjury, that the
foregoing representations are true:
on the basis of my own personal knowledge.
on the basis that I have been informed and believe
that the facts stated are true. (NOTE:
If this Petition is made solely on the basis of Petitioner’s
information and belief, Petitioner must attach affidavits by one or
more persons who have personal knowledge of the facts stated.)
DATE: ___7/20____________ __/s/x Robbin
Stewart_________________________________
PETITIONER (Signature)
__Robbin
Stewart_________________________________
PETITIONER (Type or print name)