WPC  X2@'Zҋv+< ABRB*٫'H́T|"/ uhRY& {}1;bbC>>b`jˣmܣ ې i(/:Qv>7I|JY֩(D *}HlPCX$.̑1S . .OBmvS͉xS$#eM BqG}cu ᥢ[!~.l%mf 9wVM$ G%KoԲʨ݆9g]DƅdvoU6ryE㏤) Kd/EbF Dz]3 ,aC(k+4}? 038׾\p_&k%zU0s]C`W#UN % 0: U@ ^ Y we 4i }  m N  0V; ; ; ; ;  B SAVIN_40600(9 Z6Times New Roman RegularX($USUS.,* `(CG TimesScalablem8Z zs8:i+003|xU  )USUS.,  _ @  @ rXX07/10/04(.3$ !USUS.,      d !USUS.,  _99  %_c"XXXX  INTHEDISTRICTCOURTOF______________COUNTY,KANSAS  u____________________,Plaintiff g vs.     A     I     CaseNo._______________ ? ____________________,Defendant  t   PETITIONFORPROTECTIVEORDER  L  (Pursuantto_K.S.A._Ԁ603101,etseq.)  8    r^X4` hp x (#%'0*,.8135@8:<H?AXr  1.  IliveintheCityof_________________,intheCountyof__________________,Kansas.     2.  Ihavefiled__________(givenumber)petitionsforprotectionfromabuseinthepasttwelve w  months.Thedatesofthesepetitionsare_________________________________.Thesepetitionswerefiled c inthecountiesof________________________________________.(Statewhichpetitions,ifany,involved O abuseofaminorchild)_______________________________. ;   3.  Iamseekingprotectionfor:(checkallthatapply) p {^,4` <DL!T$&)\+- 0d247l9;>t@X4` X{    _____  myself \     _____  myminorchildren(underage18) H     _____  minorchildrenwholivewithme 4   4.0  ThedefendantandI:(answerallthatapplyifyouareaskingforprotectionforyourself) $$     _____0  arecurrentlyinadatingrelationship $ $     _____0  wereformerlyinadatingrelationship $ $     _____  currentlylivetogetherinthesameresidence s     _____  formerlylivedtogetherinthesameresidence _     _____  haveneverlivedtogetherinthesameresidence K     _____  havehadachildincommon 7   0  0$$(Ifyouareallegingthatyouandthedefendantareorwereinadatingrelationship,brieflydescribe !l! thatrelationship,includingdatetherelationshipended,ifappropriate):$$N$$$ !X" $$N$$$N$$$N$    Theresidenceis:(answerifyouwantthejudgetoorderthedefendanttomove) &#' ^X4` " hp x (#%'0*,.8135@8:<H?A,X, X    _____ a)jointlyowned,orrentedandjointlyoccupiedbydefendantandme '$(     _____ b)owned,orrentedbyme o(%)     _____c)owned,orrentedbydefendantonly [)&*     _____ d)owned,orrentedbysomeoneelse(explain)$$N$ G*'+   0  0$$0 $$$$N$ $ $    _____ e)noneoftheabove(explain)$$N$ ,|)-   0  0$$0 $$$$N$ $ $    _____0 f)notapplicablebecausethedefendantandIdonotlivetogether.-T+/ $ $  .@,0   5.0  Theminorchild(_ren_):(checkallthatapplyifyouareaskingforprotectionforminorchild(_ren_))$$     _____0 iscurrentlyinadatingrelationshipwiththedefendant $ $     _____0 wasformerlyinadatingrelationshipwiththedefendant{ $ $     _____ currentlyliveswiththedefendant(andhassincethefollowingdate:򀀀) g     _____ currentlyliveswithme(andhassincethefollowingdate:򀀀) S     _____ formerlylivedwiththedefendant ?     _____ hasneverlivedwiththedefendant +     _____ hashadachildincommonwiththedefendant  t 0  0$$(Ifyouareallegingthattheminorchildandthedefendantareorwereinadatingrelationship,  L  brieflydescribethatrelationship): 8 $$ $$N$$$N$$$N$    6.  Thefollowinglegalactionshavebeenfiledbetweenmeandthedefendantorinvolvingtheminor w  children:(checkcasetype,givecountyfiledin,andgivecasenumberanddatefiled,ifknown) c   _____  divorce/custody$$N$ O   _____  paternity$$N$ ;   _____0  childinneedofcare$$N$$$ '   _____0  actionseekingprotectiveorder$$N$$$ p   _____  other$$N$ \     7.  Thefollowingminorchildrenareinvolvedinthismatter:(givefullnamesandages) 4 Name0  0$$0$$0 $$0 $ $DOB0 $ $0I$$MothersName0QI$I$0Q$Q$FathersName0!$$0 $!$!$  $$ $$        0   0I $ $     Q 0I$I$   Y  ! 0 $$$  $$ $$        0   0I $ $     Q 0I$I$   Y  ! 0 $$$  $$ $$        0   0I $ $     Q 0I$I$   Y  ! 0 $$$  $$ $$        0   0I $ $     Q 0I$I$   Y  ! 0 $$$  $$ $$        0   0I $ $     Q 0I$I$   Y  ! 0 $$$  $$ $$        0   0I $ $     Q 0I$I$   Y  ! 0 $$$  $$ $$   Ifyouarerequestingcustodyofaminorchildwhoisalsoachildofthedefendant,youmust !l! completeandattachanadditionalformconcerningjurisdiction(_UCCJEA_Ԁform). !X"    8.  Iamseekingprotectionfromabusebecausethedefendant,_______________________ #0!$ __________________(nameofpersonyouareseekingprotectionfrom)has:(checkallthatapply) $"%     _____ causedmebodilyinjuryorattemptedtocausemebodilyinjury &#'     _____ placedmeinfearofimminentbodilyinjurybythreateningme '$(     _____ causedtheminorchildrenbodilyinjuryorattemptedtocausethembodilyinjury o(%)     _____ placedtheminorchildreninfearofimminentbodilyinjury [)&*     _____0 engagedinanyofthefollowingactswithaminorunder16yearsofagewhoisnotthe G*'+ spouseofthedefendant:sexualintercourseorlewdfondlingortouchingoftheperson 3+(, ofeithertheminororthedefendant,|)- $ $  .@,0 %_c % %  9.  Theactscomplainedofoccurredonthesedates:  $$N$$$N$$$N$    10.Brieflydescribethespecificfactsaboutwhyyouareseekingaprotectionfromabuseorder: ? $$N$$$N$$$N$$$N$$$N$$$N$$$N$$$N$$$N$$$N$    11.  Thedefendantcanbefoundat:(giveallavailableaddresses) O   HOME: street$$N$ '       0 city______________________state______________zipcode$$N$ $ $ p       0 phonenumber$$N$ $ $ \       0 timeswhendefendantisusuallythere$$N$ $ $ H   WORK: street$$N$         0 city______________________state______________zipcode$$N$ $ $         0 phonenumber$$N$ $ $        0 timeswhendefendantisusuallythere$$N$ $ $  #XXXX夵#XXXX  OTHER: street$$N$ _       0 city______________________state______________zipcode$$N$ $ $ K       0 phonenumber$$N$ $ $ 7       0 timeswhendefendantisusuallythere$$N$ $ $ #   #XXXX夀,#XXXX      #XXXX夶.#XXXX  WHEREFORE,plaintiffrequeststhattheCourtissueanorderofprotectionrestrainingdefendant "D # from: #0!$ a,4 " <DL!T$&)\+- 0d247l9;>t@X4` " X    _____0 a)0 $ $abusing,molestingorinterferingwiththeprivacyorrightsoftheplaintiffandthe $"% minorchild(_ren_)%#& $ $     _____ b)0 enteringorcomingonoraroundthepremisesortheresidenceoftheplaintifflocated &#' at:$$N$ $ $ '$( 0  0$$0$$0 $$0 $ $(Giveaddressorotherdescriptionofresidencefromwhichdefendantistobe o(%) excluded.) [)&* $ $ _0  0$$0$$0 $$0 $ $Iamrequestingthatmy____addressand____telephonenumberremain  confidentialforthefollowingreason:(completeifappropriate){ $ $ 0  0$$0$$0 $$0 $ $    I      Q      Y  !   $ $   0  0$$0 $$0 $ $    I      Q      Y  !   $ $   0  0$$0 $$0 $ $    I      Q      Y  !   $ $   8  0G"G"8G"G" !!   FURTHER,plaintiffrequeststhattheCourtalsoissuethefollowingorder(s):(checkif  t appropriate)  `     _____ c)0 defendantimmediatelymovefromandnotreturntotheresidencelocatedat:  L  ________________________________________________________ 8  $ $       0 0 $ $(Youmustincludeyouraddressifdefendantisorderedtoberemovedfromthe  $  residence)   $ $     _____ d)0 lawenforcementofficersbedirectedtoevictthedefendantfromtheresidence   locatedat:____________________________________________  $ $     _____ e)0 lawenforcementofficersbedirectedtograntanyassistancenecessarytoprotect w  plaintiffandchild(ren)fromabusec $ $       Plaintifffurtherrequeststhatcopiesofordersbegiventotheappropriatelawenforcement ; agencies;thattheCourtissuean exparte orderoftemporarycustodyoftheminorchild(ren),if ' appropriate;thatadate,timeandplaceforahearingonthismatterbeset;andthatsummonsbeissuedto t defendant,notifyingthedefendantofthisactionandthereliefrequested. `   Plaintifffurtherrequeststhatuponhearingofthiscause,theCourtissueafinalorderofprotection, 8 enjoiningdefendantfromanyactsofabuseagainsttheplaintiffandtheplaintiff'schild(ren),andthatthe $ Courtawardtoplaintiffthefollowingadditionalrelief:      _____ a) suitablealternativehousingforplaintiffandminorchild(ren)      _____ b) custodyoftheminorchild(ren)(UCCJEAformcompleted)      _____ c) childsupport w     _____ d) supportofspouse c     _____ e)0 possessionofpersonalproperty,andtheassistanceofalawenforcementofficer O insecuringthatproperty,ifnecessary; $ $     _____ f) attorney'sfees,ifrepresentedbycounsel;andcosts '       _____ g) counselingfordefendant !p!     _____ h) other,pleasespecify:$$N$ !\"   0  0$$0 $$0 $ $$$N$ $ $  0  0$$0 $$0 $ $$$N$ $ $andforsuchotherandfurtherrelief,allasappropriateandastheCourtdeemsnecessary. % #&             I __________________________________________ '$(             I Plaintiff'ssignature s(%)   _)&* (Ifattorneyrepresentstheplaintiff,the  attorney'saddressandphonenumber { mustbeprovided.) g ___________________________ S ___________________________ ? ___________________________ +   VERIFICATION  `    STATEOFKANSAS  )  8           )  ss:  $  COUNTYOF__________ )      _____________________________,oflawfulage,beingfirstdulyswornstatesthat(she)(he)isthe   plaintiffintheaboveaction;that(she)(he)hasreadtheforegoingPetitionandknowsthecontentsofitand c thatthedeclarationsinitaretrueandcorrecttothebestofplaintiff'sknowledgeandbelief. ;             I __________________________________________ p             I Plaintiff'ssignature \ SIGNEDANDSWORNto(oraffirmed)beforemeonthis_____dayof_______________,______.               I __________________________________________              I ClerkoftheDistrictCourt/NotaryPublic s MyAppointmentExpires: K ___________________ 7 #XXXX/#