Arkansas Code Title 9. Family Law § 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.

(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:

				Relationship
	Children	Date of Birth	Address	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:
_________________________________________________	”.