Armata-Pripstein - Application and Instructions for Restraining Order

Filing for an Application for a Restraining Order - CT Judicial Branch
http://www.jud.ct.gov/forms/grouped/family/restraining_order.htm
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12/21/2010
Family Forms
Filing an Application for a Restraining Order
Disclaimer: The information on this web page is provided as a
service and a convenience by the Connecticut Judicial Branch. It is
not intended as legal advice to any person.
If you have questions about the use of these forms, your legal
rights, or particular issues in your case, it is strongly recommended
that you talk to an attorney.
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Due to the changing nature of the law, the forms and information found on this web site will change from
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Each court location has a Clerk's Office and many locations also have a Court Service Center that can
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Instructions
These instructions are to help you represent yourself in court. Legal words and court documents can be
confusing. The more you know, the more comfortable you will be when you fill out the necessary court
forms and come to court. These instructions will give you some useful information and instructions on
filling out the necessary forms.
Every case is different and this instruction sheet is to be used as a guide only; if you think you need
more help you may want to get an attorney. You can also go to a Court Service Center or contact the
Connecticut Network for Legal Aid or find additional information at the Law Libraries. Court staff can
answer procedural questions and help you understand the legal process, but cannot give you legal
advice.
To apply for a Restraining Order you have to fill out the following 2 forms:
• Application for Relief From Abuse (JD-FM-137)
• Affidavit- Relief From Abuse (JD-FM-138)
If you are seeking temporary custody of children, you must also fill out an:
• Affidavit Concerning Children (JD-FM-164)
The person who fills out the Application for Relief From Abuse is called the “Applicant”. The person the
Application is filed is called the “Respondent.” There are no court fees for the Application.
Once you finish your paperwork, you must take it to the Clerk’s office. Do not sign these forms until you
are in front of a court clerk or a notary public. The Application and Affidavit will be reviewed by a Judge.
Once the Judge makes a decision on your Application, the Clerk’s Office will process the papers and
return them to you. The date you have to come back to court for your hearing will be on the order form.
The paperwork must be given immediately to a State Marshal, so that he or she may deliver the
paperwork to the Respondent. You will be given a State Marshal Commission form to fill out called the
Restraining Order Service Instructions/Profile (SMC-1). This form helps the State Marshal find the
Respondent. The Clerk’s Office or the Court Service Center can give you a list of State Marshals. At
certain court locations, a State Marshal will be at the courthouse at specific times during the day to help
you with getting the papers delivered to the Respondent.
If your Application was granted, be sure to keep a copy of the paperwork with you at all times and keep
another copy in a safe place. The court will send a copy of the order to the police department.
You must be in court on the date of the hearing if you want the court to give you a restraining order or, if
the court already gave you a temporary restraining order, to keep it in place. The respondent may also
be in court. If you think you need more security when you are in court for your restraining order

Filing for an Application for a Restraining Order - CT Judicial Branch
http://www.jud.ct.gov/forms/grouped/family/restraining_order.htm
Page 2 of 2
12/21/2010
hearing, contact the Clerk's Office or the Court Service Center in the court where your hearing is
scheduled.
On the day of your hearing be sure to come to court early because it can take 10 to 20 minutes to get
into the courthouse since everyone must go through a metal detector. Be sure to bring copies of your
forms and any evidence to support your claim. Go to your assigned courtroom and wait for instructions.
If you are not sure where to go, check with the Clerk’s Office or Court Service Center.
The orders are usually good for six months after the hearing, but the judge can decide to make the
orders good for a longer or shorter amount of time. You should contact the police department
immediately if the Respondent violates any order issued.
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APPLICATION FOR
RELIEF FROM ABUSE
JD-FM-137 Rev. 2-10 C.G.S. §§ 29-28, 29-32, 29-33,
46b-15, 46b-38nn, 46b-38oo, 52-231a
Instructions
To Applicant
Instructions
To Clerk
{
{
STATE OF CONNECTICUT
SUPERIOR COURT
www.jud.ct.gov
1. Use a typewriter or print clearly in ink.You must also complete an Affidavit, form JD-FM-138. Give both forms to the Clerk of Court.
2. After your Application and Affidavit are processed, the clerk will give you the proper papers to have served on the Respondent.
3. Make sure the originals are returned to court after service.
1. If Ex Parte relief is ordered, prepare the following forms: Order of Protection, form JD-CL-99, and if applicable, Additional Orders of Protection,
form JD-CL-100; Order and Notice of Court Hearing, form JD-FM-140; General Restraining Order Notifications (Family), form JD-CL-104.
2. If Ex Parte relief is NOT ordered, prepare Order and Notice of Court Hearing, form JD-FM-140.
3. Provide the Applicant with the original and one copy of the Application and Affidavit. Retain copies of each for court file.
4. Provide the Applicant with the Procedures For Relief From Abuse Process brochure JDP-FM-142 for further information.
Judicial District of
Court location (number, street, town, zip code)
Docket number
Name of applicant (Last, first, middle initial)
Date of birth (mm/dd/yyyy) Sex (M/F) Race
Address to which mail is to be sent (number, street)
(Town) (State) (Zip Code)
Home/residence address* Same as mailing address
(Town)
(State) (Zip Code)
Work address*
(Town) (State) (Zip Code)
* NOTE: The home address and/or work address provided above will be included on any orders entered by the court. If you do
not wish to provide your home address and/or work address, do not complete these boxes. However, failure to disclose your
location information may limit the protection your can receive by the restraining order. If you believe that disclosure of location
information would jeopardize you and/or your child(ren)'s health, safety or liberty, you may file a Request For Nondisclosure of
Location Information with the Clerk of Court.
Information About The Respondent
Name of respondent (Person against whom application is filed) (Last, first, middle initial)
Date of birth (mm/dd/yyyy) Sex (M/F) Race
Address of respondent (Number, street)
(Town) (State) (Zip Code)
Respondent's telephone number
Other identifiers (Examples include height, weight and approximate age)
Respondent is ("X" all that apply)
My spouse or a person I have a civil union with
My child
My former spouse or a person I had a civil union with
A person 18 or over related to me by blood or marriage
Parent of my child
A person 16 or over with whom I reside or with whom I have resided
My parent
A caretaker who is providing shelter in his or her residence to a person 60
years of age or older
A person with whom I have (or recently had) a dating relationship
"X" here if you have cohabited with the Respondent as an intimate partner (romantic, spousal, or sexual relationship while living together).
"X" here if a Protective Order/Restraining Order exists affecting any party to this Application (Enter docket number and court location)
Docket number
Court location
"X" here if a dissolution of marriage (divorce), dissolution of civil union, custody or visitation action exists involving the same parties.
(Enter docket number and court location)
Docket number
Court location
Page 1 of 2 (continued on page 2)

Name of applicant Name of respondent Docket number
Application For Relief From Abuse
I have been subjected to a continuous threat of present physical pain or physical injury by the Respondent named above as
stated more fully in my attached Affidavit.
1. I request that the court order the following conditions: ("X" all that apply)
CT01
CT03
CT05
CT14
CT16
CT19
The Respondent not assault, threaten, abuse, harass, follow, interfere with, or stalk me. (CT01)
The Respondent stay away from my home or wherever I shall reside. (CT03)
The Respondent not contact me in any manner, including by written, electronic or telephone contact, and not
contact my home, workplace or others with whom the contact would be likely to cause annoyance or alarm to
me. (CT05)
The Respondent may return to the home one time with police to retrieve belongings. (CT14)
The Respondent stay 100 yards away from me. (CT16)
That the order protect my minor children. (CT19)
Name(Last, first, middle initial) Date of birth(mm/dd/yyyy) Relationship to me
CT31
That the order protect animals owned or kept by me. (CT31)
2. I request that the court make the following temporary child custody and visitation orders:
CT20
Award me temporary custody of the following minor child(ren) who is (are) also the child(ren) of the Respondent.
1
2
3
Name
(Last, first, middle initial)
Sex
(M/F)
Date of birth
(mm/dd/yyyy)
4
5
6
Name
(Last, first, middle initial)
Sex
(M/F)
Date of birth
(mm/dd/yyyy)
CT21
With visitation as follows:
CT22
Without visitation rights to the Respondent.
3. I request that the court order the following: (further order)
Request For Ex Parte (Immediate) Relief ("X" if applicable)
4. I request that the court order Ex Parte (immediate) relief because I believe there is an immediate and present physical
danger to me and / or my minor children and / or animals owned or kept by me.
Signed (Applicant)
Subscribed and Signed (Clerk, Notary, Commisioner of Superior Court) Date signed
sworn to before me:
Optional to applicant (If you choose to answer, "X" the appropriate boxes below)
1. Does the respondent hold a permit to carry a pistol or revolver?...................
2. Does the respondent possess one or more firearms?...................................
Yes No Unknown
Yes No Unknown
If you think you need more security when you are in court for your relief from abuse hearing, contact the Clerk's Office or the Court Service
Center in the court where your hearing is scheduled
JD-FM-137 Rev. 2-10
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