2010 Florida Statutes (including Special Session A)
INJUNCTION FOR PROTECTION
AGAINST DOMESTIC VIOLENCE
Before me, the undersigned authority, personally appeared Petitioner (Name) , who has been sworn and says that the following statements are true:
(a) Petitioner resides at: (address)
(Petitioner may furnish address to the court in a separate confidential filing if, for safety reasons, the petitioner requires the location of the current residence to be confidential.)
(b) Respondent resides at: (last known address)
(c) Respondent’s last known place of employment: (name of business and address)
(d) Physical description of respondent: ____
Date of birth____
Distinguishing marks or scars____
(e) Aliases of respondent: ____
(f) Respondent is the spouse or former spouse of the petitioner or is any other person related by blood or marriage to the petitioner or is any other person who is or was residing within a single dwelling unit with the petitioner, as if a family, or is a person with whom the petitioner has a child in common, regardless of whether the petitioner and respondent are or were married or residing together, as if a family.
(g) The following describes any other cause of action currently pending between the petitioner and respondent: __________
The petitioner should also describe any previous or pending attempts by the petitioner to obtain an injunction for protection against domestic violence in this or any other circuit, and the results of that attempt__________
Case numbers should be included if available.
(h) Petitioner is either a victim of domestic violence or has reasonable cause to believe he or she is in imminent danger of becoming a victim of domestic violence because respondent has ____(mark all sections that apply and describe in the spaces below the incidents of violence or threats of violence, specifying when and where they occurred, including, but not limited to, locations such as a home, school, place of employment, or visitation exchange)____: __________
____committed or threatened to commit domestic violence defined in s. 741.28, Florida Statutes, as any assault, aggravated assault, battery, aggravated battery, sexual assault, sexual battery, stalking, aggravated stalking, kidnapping, false imprisonment, or any criminal offense resulting in physical injury or death of one family or household member by another. With the exception of persons who are parents of a child in common, the family or household members must be currently residing or have in the past resided together in the same single dwelling unit.
____previously threatened, harassed, stalked, or physically abused the petitioner.
____attempted to harm the petitioner or family members or individuals closely associated with the petitioner.
____threatened to conceal, kidnap, or harm the petitioner’s child or children.
____intentionally injured or killed a family pet.
____used, or has threatened to use, against the petitioner any weapons such as guns or knives.
____physically restrained the petitioner from leaving the home or calling law enforcement.
____a criminal history involving violence or the threat of violence (if known).
____another order of protection issued against him or her previously or from another jurisdiction (if known).
____destroyed personal property, including, but not limited to, telephones or other communication equipment, clothing, or other items belonging to the petitioner.
____engaged in any other behavior or conduct that leads the petitioner to have reasonable cause to believe he or she is in imminent danger of becoming a victim of domestic violence.
(i) Petitioner alleges the following additional specific facts: (mark appropriate sections)
____A minor child or minor children reside with the petitioner whose names and ages are as follows: __________
____Petitioner needs the exclusive use and possession of the dwelling that the parties share.
____Petitioner is unable to obtain safe alternative housing because: __________
____Petitioner genuinely fears that respondent imminently will abuse, remove, or hide the minor child or children from petitioner because: __________
(j) Petitioner genuinely fears imminent domestic violence by respondent.
(k) Petitioner seeks an injunction: (mark appropriate section or sections)
____Immediately restraining the respondent from committing any acts of domestic violence.
____Restraining the respondent from committing any acts of domestic violence.
____Awarding to the petitioner the temporary exclusive use and possession of the dwelling that the parties share or excluding the respondent from the residence of the petitioner.
____Providing a temporary parenting plan, including a temporary time-sharing schedule, with regard to the minor child or children of the parties which might involve prohibiting or limiting time-sharing or requiring that it be supervised by a third party.
____Establishing temporary support for the minor child or children or the petitioner.
____Directing the respondent to participate in a batterers’ intervention program or other treatment pursuant to s. 39.901, Florida Statutes.
____Providing any terms the court deems necessary for the protection of a victim of domestic violence, or any minor children of the victim, including any injunctions or directives to law enforcement agencies.
I HAVE READ EVERY STATEMENT MADE IN THIS PETITION AND EACH STATEMENT IS TRUE AND CORRECT. I UNDERSTAND THAT THE STATEMENTS MADE IN THIS PETITION ARE BEING MADE UNDER PENALTY OF PERJURY, PUNISHABLE AS PROVIDED IN SECTION 837.02, FLORIDA STATUTES.
In making its determination under this paragraph, the court is not limited to those factors enumerated in subparagraphs 1.-10.
It is mandatory that such programs be certified under s. 741.32.
If the respondent has been served previously with the temporary injunction and has failed to appear at the initial hearing on the temporary injunction, any subsequent petition for injunction seeking an extension of time may be served on the respondent by the clerk of the court by certified mail in lieu of personal service by a law enforcement officer.