Petition For Protection From Abuse Page 6

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BEFORE ME, the undersigned Notary Public, duly commissioned and qualified in and for the state and
parish aforesaid, personally came and appeared
Petitioner in the foregoing Petition for Protection from Abuse, who, after being duly sworn by me, did
depose and say that s/he has read the allegations contained therein and declared them to be true and
correct to the best of her/his knowledge, information, and belief.
Petitioner further said that s/he believes that the defendant poses a threat to petitioner’s safety and/or to
the child(ren) or to others for whom petitioner has requested relief.
Petitioner further said that s/he is aware that any false statement made under oath contained in the
foregoing petition and this affidavit shall constitute perjury and shall be punishable by a fine of not more
than one thousand dollars ($1,000.00), or by imprisonment, with or without hard labor, for not more
than five (5) years, or both.
SWORN TO AND SUBSCRIBED before me, Notary Public, on the
day of
, 20
, at
, Louisiana.
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