Petition For Restraining Order Form - Kansas District (Page 2 of 3) in pdf

6. [ ] Defendant has committed a series of acts that seriously alarm, annoy, or harass plaintiff.(Specify in item 13)

7. [ ] Plaintiff has actually suffered substantial emotional distress as a direct result of defendant’s conduct and defendant’s

conduct would have caused a reasonable person to suffer substantial emotional distress. (Specify in item 13)

8. [ ] Defendant’s continuing course of conduct has been directed specifically against plaintiff and is knowing, willful, not

constitutionally protected, and without legitimate purpose. (Specify in item 13)

PLAINTIFF REQUEST THE COURT TO MAKE THE ORDERS INDICATED BY THE CHECK MARKS IN THE BOXES

BELOW.

[ ]

PERSONAL CONDUCT ORDERS TO BE ORDERED NOW AND EFFECTIVE UNTIL THE HEARING.

Restrained person must not contact, molest, harass, attach, strike, threaten, sexually assault, batter, telephone, send any

messages to follow, stalk, destroy any personal property, disturb the peace, keep under surveillance, or block movements in

public places or thoroughfares.

[ ]

10.

STAY AWAY ORDERS TO BE ORDERED NOW AND EFFECTIVE UNTIL THE HEARING.

Defendant must stay at least (specify): ______ yards away from the following person and places (the addresses of the places

are optional and you do not have to reveal them):

[ ] Plaintiff and the other named plaintiffs (names): ______________________________________________________

_____________________________________________________________________________________________

[ ] Plaintiff’s residence (address optional): _____________________________________________________________

[ ] Plaintiff’s place of work (address optional): _________________________________________________________

[ ] Plaintiff’s children’s school or place of child care (address optional): ____________________________________

[ ] Other (specify): ________________________________________________________________________________

11. Will granting of any of the stay-away orders in item 10 interfere with defendant’s access to defendant’s residence or place of

employment? [ ]Yes

[ ] No (if yes, explain): ___________________________________________________________

[ ]

12.

Plaintiff(s) will suffer great and irreparable harm before this petition can be heard in court unless the court makes those

orders requested above effective now and until the hearing. (Specify the harm and why it will occur before the hearing):

____________________________________________________________________________________________________

13. DESCRIPTION OF CONDUCT. Describe in detail the most recent incidents that has brought plaintiff to request this

restraining order. State what happened, the dates, and who did what to whom. Describe any injuries.

____________________________________________________________________________________________________

14. DATES OF INCIDENTS (You must state dates of when incidents occurred): ___________________________________

____________________________________________________________________________________________________

15 [ ] Plaintiff has asked for restraining orders against the defendant before. (Specify court and case number, if known.)

____________________________________________________________________________________________________

16. [ ] Defendant has asked for restraining orders against plaintiff before. (Specify court and case number, if known.)

____________________________________________________________________________________________________

17. OTHER ORDERS (Specify other orders you are requesting) ________________________________________________

____________________________________________________________________________________________________

18. [ ] Plaintiff is not paying a fee for filing this petition because plaintiff is seeking order(s) restraining violence or threats of

violence

. (Note: If the Court finds there have been no violence or threats of violence, then you may be ordered to pay the appropriate

fees.)

Petition For Restraining Order Form - Kansas District Page 2

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