IN THE COURT OF ,MISSISSIPPI
PETITIONER
VS. CAUSE NO.
RESPONDENT
Petitioner states that the alleged act(s) of abuse occurred in:
City: County: State:
Petitioner states that the respondent resides in:
City: County: State:
(b) Petitioner requests protection for the following other household member(s):
Additional persons listed on Supplemental Form #1 (SF1)
Petitioner requests his/her address remain confidential. (Disclosure of address would risk abuse of petitioner or
petitioner’s family or household members, or would reveal the location of a domestic violence shelter.)
Yes Address provided on Supplemental Form #2 (SF2)
No Address: City: State: Zip:
Paragraph 2
Petitioner /Self
(a) Petitioner files this petition on behalf of the following person(s) who has/have been abused by
Respondent:
Minor child(ren) and/or person(s) alleged to be incompetent.
Sex:
Male
Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native
Black White Unknown
Relationship to Respondent (must check at least one):
Current or former spouse
Currently living or formerly lived as spouse
Have child(ren) in common Current or former dating partner
Related by blood or marriage AND currently live or formerly lived together.
Date of Birth (mm/dd/yyyy):
Sex:
Male
Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native
Black White Unknown
Relationship to Respondent (must check at least one):
Current or former spouse
Currently living or formerly lived as spouse
Have child(ren) in common Current or former dating partner
Related by blood or marriage AND currently live or formerly lived together.
Date of Birth (mm/dd/yyyy):
Additional persons listed on Supplemental Form #1 (SF1)
M.C.A. § 93-21-1 et seq.
Yes No PETITIONER REQUESTS EMERGENCY RELIEF
PETITION FOR DOMESTIC ABUSE PROTECTION ORDER
Paragraph 1
Sex:
Male Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native Black
White
Unknown
Date of Birth (mm/dd/yyyy):
Sex:
Male Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native Black
White
Unknown
Date of Birth (mm/dd/yyyy):
Paragraph 3
Alcoholic Allergies Armed and Dangerous Diabetic Epilepsy Escape Risk Explosive Expertise Hemophiliac
Heart Condition International Flight Risk Known to Abuse Drugs Martial Arts Expert Medication Required
Other ____________________________________________
Sex:
Male
Female
Height: ft in
Weight: lbs
The facts and circumstance of the alleged abuse are: _
_
_
__
_
__
__
Hair
(Color/Type)
:
Black
Blond or Strawberry
Blue
Brown
Gray or Partially Gray
Green
Orange Purple Red or Auburn Sandy White Unknown
Race:
Asian / Pacific Islander
American Indian / Alaskan Native
Black
White
Unknown
Social Security Number (###-##-####): - -
Distinguishing Features
(tattoos, birth marks, scars, etc)
:
State:
Expiration Date
(mm/dd/yyyy)
:
Driver License Number:
Aliases (Other names the respondent is or has been known as.):
Respondent’s Information
Name (last, first, middle)
:
Address 1:
Address 2:
City: State: Zip: County:
Place of Employment:
Date of Birth (mm/dd/yyyy):
Paragraph 4
Eye Color:
Black
Brown
Green
Maroon
Pink
Blue
Gray
Hazel
Multicolored
Unknown
The Respondent abused the person(s) listed in Paragraph 1(a) by committing the following acts:
Attempted to cause or intentionally, knowingly or recklessly caused bodily injury;
Placed, by physical menace or threat, in fear of imminent serious bodily injury;
Criminal sexual conduct against a minor;
Stalking or cyber-stalking; or
Sexual battery or rape.
Paragraph 5
Paragraph 6
Additional Information provided on Supplemental Form #3 (SF3)
Caution and Medical Conditions (Check all that apply)
Yes No A suit for divorce is pending. If yes, where
Yes
No A divorce has been granted.
If yes, where
(If yes, a copy of the divorce decree must be provided to the court before the hearing on this petition.)
Paragraph 7
Additional persons listed on Supplemental Form #4 (SF4)
Sex:
Male
Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native
Black White Unknown
A court order for custody or visitation has been granted.
Yes (
If yes, provide a copy to the court before the hearing on this petition.)
No
Date of Birth (mm/dd/yyyy):
Yes No The Respondent and _________________________, who is listed in Paragraph 1(a), have
child(ren) in common
Sex:
Male
Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native
Black White Unknown
A court order for custody or visitation has been granted.
Yes (
If yes, provide a copy to the court before the hearing on this petition.)
No
Date of Birth (mm/dd/yyyy):
Paragraph 8
Petitioner requests this Court to enter a Protection Order granting the following relief:
Prohibit the Respondent from abusing, harassing, stalking, following or threatening in any manner whatsoever,
including by electronic means, the person(s) listed in Paragraph 1(a). This also includes the use, attempted use or
threatened use of force or physical violence that would reasonably be expected to cause bodily injury.
Prohibit the Respondent from contact with the person(s) listed in Paragraph 1, either in person, by phone, electronic
communication, or through a third party, except such contact as may be necessary for the purposes set forth below.
Prohibit the Respondent from going within a certain distance to the person(s) listed in Paragraph 1, with the following
exceptions:
Prohibit the Respondent from transferring or disposing of property which is mutually owned by the parties.
Authorize the Petitioner sole use of the residence located at:
to the exclusion of the Respondent by evicting Respondent.
Direct the appropriate law enforcement agency to assist the person(s) listed in Paragraph 1(a) in obtaining:
Possession of the residence by evicting Respondent.
Possession of personal clothing and other necessities belonging to the person(s) listed in Paragraph 1(a) from:
The shared residence
The respondent’s residence
Other location
Require the Respondent to pay the costs of court in this matter.
Other relief deemed appropriate and necessary by the Court.
Exceptions to the contact and/or distance prohibition(s) should include:
For purposes of exchanging the minor child(ren) for visitation;
For medical emergencies involving the minor children;
For special events involving the minor children as deemed appropriate by the Court; or
Other (be specific): .
Paragraph 9
RESPECTFULLY SUBMITTED, this the day of , 20 .
Petitioner’s Signature
STATE OF MISSISSIPPI
COUNTY/CITY OF
PERSONALLY CAME AND APPEARED BEFORE ME, the undersigned authority in and for the
jurisdiction aforesaid, the within named , who, after being by
me first duly sworn on oath, stated that the facts set out in the above and foregoing Petition are true and
correct as therein stated.
SWORN TO AND SUBSCRIBED BEFORE ME, this the day of , 20 .
My Commission Expires:
Notary Public/Court Clerk
Do not check any of the following unless this petition is being filed in the Chancery or County Court.
Award temporary custody and/or support of any minor child(ren) listed in paragraph 8.
Establish a temporary visitation schedule for minor children listed in paragraph 8.
Order Respondent to provide monetary support for Petitioner and/or any incompetent person listed in Paragraph1(a).
Order Respondent to pay restitution for losses suffered as a direct result of the abuse to the person(s) listed in
Paragraph 1(a).
Paragraph 9 (Continued)
Copies to: Court File Petitioner Law Enforcement Agency(ies) for service on Respondent with Summons
Please specify in detail if you have any petitions for protection pending in another court and/or have any protection
orders (including emergency orders) currently in place against the Respondent identified in this Petition which
are/were based on the same allegations of abuse contained herein.
.
.
.
I currently have no petitions pending and no orders issued against Respondent.
If you have a petition pending in another court against Respondent and/or another Court has issued a
protection order (emergency, temporary, or final), please be prepared to provide this Court with a copy of
the petition and any orders.
Paragraph 10
Sex:
Male
Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native
Black White Unknown
Relationship to Respondent (must check at least one):
Current or former spouse
Currently living or formerly lived as spouse
Have child(ren) in common Current or former dating partner
Related by blood or marriage AND currently live or formerly lived together.
Date of Birth (mm/dd/yyyy):
Supplement to Paragraph 1(a)
Petitioner files this petition on behalf of the following minor child(ren) and/or persons(s) alleged to
be incompetent:
Sex:
Male
Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native
Black White Unknown
Relationship to Respondent (must check at least one):
Current or former spouse
Currently living or formerly lived as spouse
Have child(ren) in common Current or former dating partner
Related by blood or marriage AND currently live or formerly lived together.
Date of Birth (mm/dd/yyyy):
Sex:
Male
Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native
Black White Unknown
Relationship to Respondent (must check at least one):
Current or former spouse
Currently living or formerly lived as spouse
Have child(ren) in common Current or former dating partner
Related by blood or marriage AND currently live or formerly lived together.
Date of Birth (mm/dd/yyyy):
Sex:
Male
Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native
Black White Unknown
Relationship to Respondent (must check at least one):
Current or former spouse
Currently living or formerly lived as spouse
Have child(ren) in common Current or former dating partner
Related by blood or marriage AND currently live or formerly lived together.
Date of Birth (mm/dd/yyyy):
Supplement to Paragraph 1(b)
Petitioner requests protection for the following other household member(s):
Sex:
Male Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native Black
White
Unknown
Date of Birth (mm/dd/yyyy):
Sex:
Male Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native Black
White
Unknown
Date of Birth (mm/dd/yyyy):
Sex:
Male Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native Black
White
Unknown
Date of Birth (mm/dd/yyyy):
Sex:
Male Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native Black
White
Unknown
Date of Birth (mm/dd/yyyy):
SUPPLEMENTAL FORM #1 (SF1)
PETITION FOR DOMESTIC ABUSE PROTECTION ORDER
Paragraphs 1(a) and (b) Continued
SUPPLEMENTAL FORM #2 (SF2)
PETITION FOR DOMESTIC ABUSE PROTECTION ORDER
CONFIDENTIAL ADDRESS INFORMATION
Paragraph 2 Continued
§ 93-21-9(7) If the petition states that the disclosure of the petitioner's address would risk abuse of
the petitioner or any member of the petitioner's family or household, or would reveal the confidential
address of a shelter for domestic violence victims, the petitioner's address may be omitted from the
petition. If a petitioner's address has been omitted from the petition pursuant to this subsection and
the address of the petitioner is necessary to determine jurisdiction or venue, the disclosure of such
address shall be made orally and in camera. A nonpublic record containing the address and contact
information of a petitioner shall be maintained by the court to be utilized for court purposes only.
Petitioner has requested his/her address remain confidential. (Disclosure of address would risk abuse of
petitioner or petitioner’s family or household members, or would reveal the location of a domestic violence shelter.)
If filing on behalf of a minor or person alleged to be incompetent, does the minor/person incompetent reside
with the petitioner?
Yes
No
Petitioner’s Home Phone Number:
Cell Phone Number:
Work Phone Number:
Other Contact Name:
Other Contact Number:
Petitioner’s Address
Name (last, first, middle):
Address 1:
Address 2:
Minor or person alleged to be incompetent’s address:
Name (last, first, middle):
Address 1:
Address 2:
SUPPLEMENTAL FORM #4 (SF4)
PETITION FOR DOMESTIC ABUSE PROTECTION ORDER
Children in Common with Respondent
Paragraph 8 Continued
Sex:
Male
Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native
Black White Unknown
A court order for custody or visitation has been granted.
Yes (
If yes, provide a copy to the court before the hearing on this petition.)
No
Date of Birth (mm/dd/yyyy):
Sex:
Male
Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native
Black White Unknown
A court order for custody or visitation has been granted.
Yes (
If yes, provide a copy to the court before the hearing on this petition.)
No
Date of Birth (mm/dd/yyyy):
Sex:
Male
Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native
Black White Unknown
A court order for custody or visitation has been granted.
Yes (
If yes, provide a copy to the court before the hearing on this petition.)
No
Date of Birth (mm/dd/yyyy):
Sex:
Male
Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native
Black White Unknown
A court order for custody or visitation has been granted.
Yes (
If yes, provide a copy to the court before the hearing on this petition.)
No
Date of Birth (mm/dd/yyyy):
Sex:
Male
Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native
Black White Unknown
A court order for custody or visitation has been granted.
Yes (
If yes, provide a copy to the court before the hearing on this petition.)
No
Date of Birth (mm/dd/yyyy):
Sex:
Male
Female
Race:
Asian or Pacific Islander
American Indian or Alaskan Native
Black White Unknown
A court order for custody or visitation has been granted.
Yes (
If yes, provide a copy to the court before the hearing on this petition.)
No
Date of Birth (mm/dd/yyyy):