Application for Relief From Abuse, JD-FM-137 Instructions

Please enter the street number and name of your home or residence address. Fill only if 'Same as mailing address' is 'No'.

Check this box if your home or residence address is identical to the mailing address you provided.

Please enter the town of your home or residence address. Fill only if 'Same as mailing address' is 'No'.

Please enter the state of your home or residence address. Fill only if 'Same as mailing address' is 'No'.

Please enter the zip code of your home or residence address. Fill only if 'Same as mailing address' is 'No'.

Enter the street number and street name for the applicant's mailing address.

Enter the town or city for the applicant's mailing address.

Enter the state for the applicant's mailing address.

Enter the zip code for the applicant's mailing address.

Enter your full name as the applicant, including your last name, first name, and middle initial.

Provide your date of birth.

Indicate your sex, either M for Male or F for Female.

State your racial or ethnic origin.

Check this box if you are currently enrolled in school and ask that a copy of the restraining order, if it is granted, be sent to your school.

Enter the full name of the applicant's school. Fill only if 'Applicant is in school and requests copy of order sent to school' is 'Yes'.

Enter the fax number of the applicant's school. Fill only if 'Applicant is in school and requests copy of order sent to school' is 'Yes'.

Enter the street number and street name of the applicant's school address. Fill only if 'Applicant is in school and requests copy of order sent to school' is 'Yes'.

Enter the town or city where the applicant's school is located. Fill only if 'Applicant is in school and requests copy of order sent to school' is 'Yes'.

Enter the state where the applicant's school is located. Fill only if 'Applicant is in school and requests copy of order sent to school' is 'Yes'.

Enter the zip code of the applicant's school. Fill only if 'Applicant is in school and requests copy of order sent to school' is 'Yes'.

Enter the street number and street name of the applicant's work address.

Enter the town of the applicant's work address.

Enter the state of the applicant's work address.

Enter the zip code of the applicant's work address.

Check this box if you are asking the court to make temporary child custody and visitation orders.

Check this box if you are requesting the court to award you temporary custody of the minor child(ren) listed. Fill only if 'Request Child Custody and Visitation Orders' is 'Yes'.

Check this box if you are requesting specific visitation terms for the Respondent with the minor child(ren). Fill only if 'Request Child Custody and Visitation Orders' is 'Yes'.

Check this box if you are requesting that the Respondent not be granted visitation rights to the minor child(ren). Fill only if 'Request Child Custody and Visitation Orders' is 'Yes'.

Check this box if your minor child or children for whom you are seeking protection are in school and you want a copy of the restraining order sent to their school. Fill only if the 'That the order protect my minor children' is 'Yes'.

Enter the full name of the child's school. Fill only if 'Send copy of the restraining order to minor child(ren)’s school' is 'Yes'.

Enter the fax number of the child's school. Fill only if 'Send copy of the restraining order to minor child(ren)’s school' is 'Yes'.

Enter the street number and name of the child's school address. Fill only if 'Send copy of the restraining order to minor child(ren)’s school' is 'Yes'.

Enter the town or city where the child's school is located. Fill only if 'Send copy of the restraining order to minor child(ren)’s school' is 'Yes'.

Enter the state where the child's school is located. Fill only if 'Send copy of the restraining order to minor child(ren)’s school' is 'Yes'.

Enter the zip code of the child's school. Fill only if 'Send copy of the restraining order to minor child(ren)’s school' is 'Yes'.

Enter the name of the judicial district where this case is being filed.

Provide the full address of the court, including the number, street, town, and zip code.

Enter the unique docket number assigned to this case by the court.

Check this box if you want the court to order the Respondent not to assault, threaten, abuse, harass, follow, interfere with, or stalk you.

Check this box if you want the court to order the Respondent to stay away from your home or any place you reside.

Check this box if you want the court to order the Respondent not to contact you in any manner, including through written, electronic, telephone, or through your home, workplace, or other individuals.

Check this box if you want the court to allow the Respondent to return to the home one time, accompanied by police, to retrieve their belongings.

Check this box if you have moved out of the Respondent's home and want the court to order the Respondent to permit you to return one time, accompanied by police, to retrieve your belongings.

Check this box if you want the court to order the Respondent to maintain a distance of 100 yards from you.

Check this box if you want the court order to include protection for your minor children.

Check this box if you want the court order to include protection for animals you own or keep.

Check this box if you are requesting Ex Parte (immediate) relief because you believe there is an immediate and present physical danger to you and/or your minor children and/or animals you own or keep.

Check this box if a dissolution of marriage (divorce), dissolution of civil union, custody, or visitation action currently exists involving you and the Respondent.

Provide the docket number for any existing dissolution of marriage, civil union, custody, or visitation action involving you and the respondent. Fill only if 'Existing Dissolution or Custody Action' is 'Yes'.

Enter the court location where the existing dissolution of marriage, civil union, custody, or visitation action involving you and the respondent is filed. Fill only if 'Existing Dissolution or Custody Action' is 'Yes'.

Check this box if you know about any other protective or restraining order that currently exists involving you or the Respondent.

Please provide the docket number for any existing protective or restraining order that involves you or the Respondent. Fill only if 'Known Protective or Restraining Order' is 'Yes'.

Please provide the court location for any existing protective or restraining order that involves you or the Respondent. Fill only if 'Known Protective or Restraining Order' is 'Yes'.

Please enter the full name of the fifth child for whom temporary custody is sought, in the format Last, First, Middle Initial. Fill only if 'Award Temporary Custody' is 'Yes'.

Please enter the sex of the fifth child, either 'M' for male or 'F' for female. Fill only if 'Award Temporary Custody' is 'Yes'.

Please enter the date of birth of the fifth child. Fill only if 'Award Temporary Custody' is 'Yes'.

Enter the full name of the fifth minor child, including last name, first name, and middle initial. Fill only if 'That the order protect my minor children.' is 'Yes'.

Enter the sex of the fifth minor child, either 'M' for male or 'F' for female. Fill only if 'That the order protect my minor children.' is 'Yes'.

Enter the date of birth for the fifth minor child. Fill only if 'That the order protect my minor children.' is 'Yes'.

Enter the full name of the first child, including last, first, and middle initial. Fill only if 'Award Temporary Custody' is 'Yes'.

Enter the sex of the first child, either 'M' for male or 'F' for female. Fill only if 'Award Temporary Custody' is 'Yes'.

Enter the date of birth for the first child. Fill only if 'Award Temporary Custody' is 'Yes'.

Enter the full name of the first minor child, including last name, first name, and middle initial. Fill only if 'That the order protect my minor children.' is 'Yes'.

Enter the sex of the first minor child (M for male or F for female). Fill only if 'That the order protect my minor children.' is 'Yes'.

Enter the date of birth of the first minor child. Fill only if 'That the order protect my minor children.' is 'Yes'.

Enter the full name of the fourth child for whom temporary custody is requested, in the format of Last, First, Middle Initial. Fill only if 'Award Temporary Custody' is 'Yes'.

Enter the sex of the fourth child for whom temporary custody is requested (M for Male or F for Female). Fill only if 'Award Temporary Custody' is 'Yes'.

Enter the date of birth for the fourth child for whom temporary custody is requested. Fill only if 'Award Temporary Custody' is 'Yes'.

Please enter the full name of the fourth minor child, including last name, first name, and middle initial. Fill only if 'That the order protect my minor children.' is 'Yes'.

Please enter the sex of the fourth minor child, indicating 'M' for male or 'F' for female. Fill only if 'That the order protect my minor children.' is 'Yes'.

Please enter the date of birth for the fourth minor child. Fill only if 'That the order protect my minor children.' is 'Yes'.

Check this box if you are asking the court to make additional orders not specified in the other sections of this form.

Please provide a detailed explanation of any further orders you are requesting from the court. Fill only if 'Further Order' is 'Yes'.

Check this box if the respondent is your spouse or a person with whom you have a civil union.

Check this box if the respondent is your spouse or civil union partner and you are seeking additional orders of maintenance from them.

Check this box if you have cohabited with the respondent as an intimate partner in a romantic, spousal, or sexual relationship while living together.

Check this box if the respondent is the parent of your child.

Check this box if the respondent is your parent.

Check this box if the respondent is your child.

Check this box if the respondent is the parent of your dependent child or children in common, and you all live together.

Check this box if the respondent is the parent of your dependent child or children and you are seeking additional orders of maintenance from them.

Check this box if the respondent is related to you by blood or marriage.

Check this box if you currently reside or previously resided with the respondent.

Check this box if the respondent is a caretaker providing shelter to a person 60 years of age or older.

Check this box if you have, or recently had, a dating relationship with the respondent.

Enter the street number and name for the respondent's address.

Enter the town for the respondent's address.

Enter the state for the respondent's address.

Enter the zip code for the respondent's address.

Check this box if the respondent possesses ammunition.

Check this box if the respondent does not possess ammunition.

Check this box if it is unknown whether the respondent possesses ammunition.

Check this box if the respondent holds an eligibility certificate for a pistol or revolver, a long gun eligibility certificate, or an ammunition certificate.

Check this box if the respondent does not hold an eligibility certificate for a pistol or revolver, a long gun eligibility certificate, or an ammunition certificate.

Check this box if you do not know whether the respondent holds an eligibility certificate for a pistol or revolver, a long gun eligibility certificate, or an ammunition certificate.

Check this box if the respondent possesses one or more firearms.

Check this box if the respondent does not possess any firearms.

Check this box if it is unknown whether the respondent possesses one or more firearms.

Enter the telephone number of the respondent.

Provide any other identifying information for the respondent, such as height, weight, or approximate age.

Enter the full name of the respondent, including last, first, and middle initial.

Enter the date of birth for the respondent.

Indicate the sex of the respondent as either 'M' for male or 'F' for female.

Enter the race or ethnicity of the respondent.

Check this box if the respondent holds a permit to carry a pistol or revolver.

Check this box if the respondent does not hold a permit to carry a pistol or revolver.

Check this box if you do not know whether the respondent holds a permit to carry a pistol or revolver.

Enter the full name of the second child (last, first, middle initial) for temporary custody. Fill only if 'Award Temporary Custody' is 'Yes'.

Enter the sex of the second child (M for male or F for female) for temporary custody. Fill only if 'Award Temporary Custody' is 'Yes'.

Enter the date of birth of the second child for temporary custody. Fill only if 'Award Temporary Custody' is 'Yes'.

Enter the full name of the second minor child, including last name, first name, and middle initial. Fill only if 'That the order protect my minor children.' is 'Yes'.

Enter the sex of the second minor child as 'M' for male or 'F' for female. Fill only if 'That the order protect my minor children.' is 'Yes'.

Enter the date of birth for the second minor child. Fill only if 'That the order protect my minor children.' is 'Yes'.

Please provide the full printed name of the person signing this document.

Please provide the date this document was signed.

Provide the full name of the sixth child for temporary custody, including last name, first name, and middle initial. Fill only if 'Award Temporary Custody' is 'Yes'.

Indicate the sex of the sixth child for temporary custody. Fill only if 'Award Temporary Custody' is 'Yes'.

Provide the date of birth for the sixth child for temporary custody. Fill only if 'Award Temporary Custody' is 'Yes'.

Please enter the full name of the sixth minor child, including last name, first name, and middle initial. Fill only if 'That the order protect my minor children.' is 'Yes'.

Please indicate the sex of the sixth minor child. Fill only if 'That the order protect my minor children.' is 'Yes'.

Please enter the date of birth for the sixth minor child. Fill only if 'That the order protect my minor children.' is 'Yes'.

Please provide the full name of the third minor child, including last, first, and middle initial. Fill only if 'Award Temporary Custody' is 'Yes'.

Indicate the sex of the third minor child as either 'M' for male or 'F' for female. Fill only if 'Award Temporary Custody' is 'Yes'.

Enter the date of birth for the third minor child. Fill only if 'Award Temporary Custody' is 'Yes'.

Please provide the full name of the third minor child to be protected, including last name, first name, and middle initial. Fill only if 'That the order protect my minor children.' is 'Yes'.

Please provide the sex of the third minor child to be protected, indicating either 'M' for male or 'F' for female. Fill only if 'That the order protect my minor children.' is 'Yes'.

Please provide the date of birth for the third minor child to be protected. Fill only if 'That the order protect my minor children.' is 'Yes'.

Please describe the specific details and arrangements for visitation. Fill only if 'With Visitation as Follows' is 'Yes'.