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
Petitioner	Judge Mag
:	XPAR FULL
CAGR DISM
Address (Safe mailing address)	:	Order Effective Until
City, State, Zip Code	:	Case No.
Date of Birth	:	Judge/Magistrate
v.	:	PETITION FOR DATING VIOLENCE CIVIL
PROTECTION ORDER (R.C. 3113.31)
:
Respondent
:
Address (If home address unknown, put work address)
:
City, State, Zip Code
:
Date of Birth
CHECK ALL BOXES THAT APPLY. 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.
I need or a witness needs a foreign language interpreter in
or an American Sign Language interpreter per Sup.R. 88.
1.	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.
2.	I am filing the Petition because I am in fear of continuing danger. I am or was in a dating relationship with Respondent within one year before the violence took place.
3.	I have listed below all family or household members who need protection other than me (Leave blank if you are not seeking protection for other family or household members.)
NAME	DATE OF BIRTH	relationship to PETITIONER
4.	Respondent committed an act of violence against me.
5.	Respondent was 18 years old or older when the violence took place.
6.	I have or had a romantic or intimate relationship with the Respondent.
7.	My relationship with Respondent was neither a casual acquaintance nor an ordinary business or social relationship.
8.	You must describe the relationship with Respondent. You may include: (If you need more space, attach an additional page.) Whether you developed a special bond beyond a casual acquaintanceship or an ordinary business or social relationship Length of the relationship with Respondent Nature and frequency of contact with Respondent, including whether you had an intimate relationship with Respondent and communications that would show the relationship with Respondent was more than a casual acquaintanceship or an ordinary business or social relationship Expectations about the relationship with Respondent Statements or conduct by Respondent or you that could show to the Court the depth of or commitment to the relationship Any other reason or explanation to prove the dating relationship
9.	You must describe Respondent’s threats or actions that made you afraid. When did it happen (if you do not know exact dates, give approximate dates)? Explain why you believe you are in danger. If you need more space, attach an additional page.
10.	You may want to describe, if you want and know, about any of the following. Not describing these items in the Petition does not mean dating 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
11.	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 not remove, damage, hide, harm, or dispose of any companion animals or pets owned or possessed by Petitioner.
e.	Grants Petitioner permission to take Petitioner’s pets or companion animals, as described below, away from the possession of Respondent:
f.	Directs Respondent to complete counseling, substance abuse counseling, or other treatment or intervention as determined necessary by the Court.
g.	Directs the wireless service provider to separate Petitioner’s account from Respondent’s account, per R.C. 3113.45 to 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. The Respondent’s billing telephone number is	.
Petitioner’s contact 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 is:
h.	Includes the following additional provisions:
12.	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.
13.	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).
14.	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.
15.	Petitioner has listed court cases (including children service/CPS case, animal cruelty, sexually oriented offense, no contact order, and protection order) and other legal matters regarding Respondent which may relate to this case: (If you need more space, attach an additional page.)
CASE NAME	CASE NUMBER	COURT/COUNTY	TYPE OF CASE	RESULT OF CASE
I swear or affirm that the answers above are true, complete, and accurate to the best of my knowledge. I understand that making false statements in this document may result in a contempt of court finding against me, which could result in a jail sentence and fine, and may also subject me to criminal penalties for perjury under R.C. 2921.11.
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

IN THE COURT OF COMMON PLEAS
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