COURT OF COMMON PLEAS	For Court Use Only
DIVISION OF DOMESTIC RELATIONS	Prior Filing Yes No
HAMILTON COUNTY, OHIO	E/Z #
Case # Active: Y / N
Judge Mag
:	Case # DV
Judge Mag
XPAR FULL
:	CAGR DISM
Order Effective Until
Petitioner	:
Case No.
Address (Safe mailing address)	:
Judge
City, State, Zip Code	:
Magistrate
Date of Birth	:
PETITION FOR DOMESTIC VIOLENCE CIVIL
v.	:	PROTECTION ORDER (R.C. 3113.31)
:
Respondent
:
Address (If home address unknown, put work address)
:
City, State, Zip Code
:
Date of Birth	Respondent is 18 years old or older
IF YOU ARE ASKING FOR YOUR ADDRESS TO BE KEPT CONFIDENTIAL, PLEASE PUT A MAILING ADDRESS WHERE YOU CAN SAFELY RECEIVE MAIL. IF YOU ARE A PARTICIPANT IN THE SECRETARY OF STATE’S ADDRESS CONFIDENTIALITY PROGRAM, PLEASE USE THE P.O. BOX ADDRESS GIVEN TO YOU. THIS FORM IS A PUBLIC RECORD.
1.	I need or witness needs a foreign language	or an American Sign Language
interpreter per Sup.R. 88.
2.	I want do not want an ex parte (emergency) protection order per R.C. 3113.31. Petitioner further requests a full hearing trial be scheduled, even if the ex parte protection order is granted, denied, or not requested.
3.	Who needs protection?
Me
My minor children
A family or household member who is not a minor child
Other
4.	What is the domestic violence victim’s relationship to Respondent?
Spouse of Respondent	Child of Respondent
Former spouse of Respondent	Parent of Respondent
Natural parent of Respondent’s child	Foster Parent

Other relative (by blood or marriage) of Respondent/ Petitioner who has lived with Respondent at any time	Person “living as a spouse of Respondent” is defined as: now cohabiting; or cohabited within five years before the alleged act of domestic violence
5.	I have listed below all family or household members who need protection, other than me or the person for whom I am filing the Petition. (Leave blank if you are not including other family or household members.)
NAME	DATE OF BIRTH	RELATIONSHIP TO PETITIONER	RELATIONSHIP TO RESPONDENT	THIS PERSON LIVES WITH PETITIONER
YES NO
YES NO
YES NO
YES NO
6.	Petitioner requests a Domestic Violence Civil Protection Order. You must describe Respondent’s threats or actions that made you request a protection order, including if children were present when the acts took place. When did it happen? (If you do not know exact dates, give approximate dates). Explain why you believe you or your family or household members are in danger. If you need more space, attach an additional page.
7.	(Optional) You may describe, if you want and know, about any of the following items. Not describing these items in the Petition does not mean domestic violence did not happen. If you need more space, attach an additional page: Respondent’s history of domestic violence or other violent acts; Respondent’s history of violating court orders; Respondent’s mental health; Respondent’s threats to other persons; Respondent’s access to deadly weapons, firearms, and ammunition or use of deadly weapons and acts or threats of violence with deadly weapon; Respondent’s abuse alcohol or controlled substances (drugs); Respondent’s violence resulted in serious physical injury, forced sex, strangulation (or choking), abuse during pregnancy, abuse of the family’s pet, and/or forced entry to gain access to Petitioner or Petitioner’s family and household members; Recent separation from Respondent or relationship was recently terminated; Respondent’s obsessive and controlling behaviors, including stalking, spying, following, and/or isolating you (Petitioner); Respondent’s threats to kill self or others.
8.	Petitioner is in fear and in continuing danger.
9.	Petitioner further requests that the Court grant relief under R.C. 3113.31 to protect Petitioner and/or the family or household members named in this Petition from domestic violence by granting a civil protection order that (check all boxes that apply):
(a)	Directs Respondent to not abuse Petitioner and the family or household members named in this Petition by harming, attempting to harm, threatening, following, stalking, harassing, forcing sexual relations upon them, or by committing sexually oriented offenses against them.
(b)	Directs Respondent to not enter, approach, or contact by any means the residence, school, business, and place of employment of Petitioner and the family or household members named in this Petition.
(c)	Directs Respondent to not approach or have contact by any means with Petitioner and the family or household members named in this Petition.
(d)	Directs Respondent to leave, not return to, or interfere with Petitioner’s right to occupy the residence, including but not limited to cancelling any utilities or insurance or interrupting phone service, mail delivery, or the delivery of any other documents or items, and grants Petitioner exclusive possession of the following residence:
(e)	Allocates temporary parental rights and responsibilities for the care of the following minor children to Petitioner until further Order of the Court (include names and birth dates of the minor children):
Petitioner has completed and attached the Information for Parenting Proceeding, Form 10.01-F and it is incorporated herein.
(f)	Establishes or modifies parenting time with the following minor children and requires parenting time to be suspended or supervised or to occur under such conditions that the Court determines will ensure the safety of Petitioner and the minor children (include names and birth dates of the minor children):
Petitioner has completed and attached the Information for Parenting Proceeding, Form 10.01-F and it is incorporated herein.
(g)	Directs Respondent to provide financial support for Petitioner and the family or household members named in this Petition (Court may request additional information).
(h)	Directs Respondent to not remove, damage, hide, harm, or dispose of any property, companion animals, or pets owned or possessed by Petitioner.
(i)	Grants Petitioner permission to take Petitioner’s companion animals or pets, as described below, away from the possession of Respondent:
(j)	Divides household and family personal property as follows:
(k)	Directs Respondent to permit Petitioner to have exclusive use of the following motor vehicle:
(l)	Directs Respondent to complete batterer counseling, substance abuse counseling, or other treatment or intervention as determined necessary by the Court.
(m)	Directs the wireless service provider to separate Petitioner’s account from Respondent’s account, per R.C. 3113.45 through 3113.459. Petitioner will assume all financial responsibility for any costs associated with the wireless service number and any costs for the device associated with the wireless service number.
Respondent’s billing telephone number is:
Petitioner’s contract information is on page 1 of this Petition. The wireless service numbers to be transferred to Petitioner which are used by Petitioner or the minor children in the care of
Petitioner are:
(n)	Includes the following additional provisions:
10.	Petitioner further requests that the Court issue no mutual protection orders or other orders against Petitioner unless all of the conditions of R.C. 3113.31(E)(4) are met.
11.	Petitioner further requests that if Petitioner has a victim advocate, the Court permit the victim advocate to accompany Petitioner at all stages of these proceedings as required by R.C. 3113.31(M).
12.	Petitioner further requests at the ex parte hearing or full hearing that the Court grant such other relief as the Court considers equitable and fair, including orders or directives to law enforcement.
13.	Petitioner has listed court cases (including divorce, custody, visitation, paternity, child support, children service/CPS case, animal cruelty, sexually oriented offense, no contact order, and protection order) and other legal matters regarding Respondent that may relate to this case: (Attach additional pages, if necessary.)
CASE NAME	CASE NUMBER	COURT/COUNTY	TYPE OF CASE	RESULT OF CASE
The information above is true, complete, and accurate to the best of my knowledge. I understand that knowingly providing false information in this document may result in a contempt of court finding against me which could result in a jail sentence and fine, or criminal penalties under R.C. 2921.13.
SIGNATURE OF PETITIONER	DATE
IF YOU DO NOT HAVE AN ATTORNEY, PLEASE LEAVE THE INFORMATION BELOW BLANK.
Signature of Attorney	Attorney’s Registration Number
Name of Attorney	Attorney’s Telephone
Attorney’s Address	Attorney’s Fax
City, State, Zip Code	Attorney’s Email

COURT OF COMMON PLEAS
DIVISION OF DOMESTIC RELATIONS
HAMILTON COUNTY, OHIO
Petitioner	:	Case No.
v.	:	Judge/Magistrate
Respondent	:
REQUEST FOR SERVICE
TO THE CLERK OF COURT:
Pursuant to Civ.R. 65.1(C)(2), please serve Respondent a copy of the Petition, ex parte protection order, if granted, and any other accompanying documents to the address below and as follows:
Personal service	Certified Mail, Return Receipt Requested
Other (specify)
Other (address):
Personal service	Certified Mail, Return Receipt Requested
Other (specify)
SPECIAL INSTRUCTIONS TO SHERIFF:
Signature of Attorney OR Petitioner
RETURN OF SERVICE
Respondent was served on	.
Officer and Badge Number	Law Enforcement Agency
Date
CLERK’S CERTIFICATE OF MAILING
Service of Process was sent by	this	day of
.
Attest:	Deputy Clerk