Arkansas & U.S. Codes Related
to Domestic ViolenceSample Petition
for Order of Protection
from Arkansas Code
[see actual samples from the counties]
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
_ have or have had a child in common
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.
_ I am involved in pending litigation with the respondent in the case of:
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:
___________________________________