Arkansas Code
Subchapter 2 - Judicial Proceedings
§ 9-15-203. Petition — Form

(a) The circuit clerk shall provide simplified forms and clerical assistance to help petitioners with the writing and filing of a petition under this chapter if the petitioner is not represented by counsel.
(b) The petition form shall not require or suggest that a petitioner include his or her Social Security number or the Social Security number of the respondent in the petition.
(c)
(1)
(A) A petitioner may omit his or her home address or business address from all documents filed with the court.
(B) If a petitioner omits his or her home address, the petitioner shall provide the court with a mailing address.

(2) If disclosure of a petitioner's home address is necessary to determine jurisdiction or consider venue, the court may order the disclosure of the petitioner's home address:
(A) After receiving the petitioner's consent;
(B) Orally and in chambers, out of the presence of the respondent, and a sealed record to be made; or
(C) After a hearing, if the court takes into consideration the safety of the petitioner and finds the disclosure in the interest of justice.

(d) The petition may be in substantially the following form:
“Petition for Order of Protection Case No. Petitioner's home address: Petitioner Date of Birth Petitioner's work address: vs. Respondent's home address: Respondent Date of Birth, 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. I am an employee or volunteer of a domestic violence shelter or program, and I am filing on behalf of a minor. 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 cohabit; Are former spouses; Formerly resided together or cohabited; Have or have had a child in common; or Are presently or in the past have been in a dating relationship. 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 and Name of 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 and Name of 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: ”.
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