Application for Order of Protection · Step 3 of 6

Children

Is there custody case currently pending?: Yes Check Yes if a child custody case is going on right now. Is there custody case currently pending?: No Check No if there is no custody case happening right now. Do you and the Respondent have any child custody orders in place?: Yes Check Yes if a court has already given orders about who cares for the children. Do you and the Respondent have any child custody orders in place?: No Check No if there are no court orders about the children yet. Do you have an open CPS case?: Yes Check Yes if Child Protective Services has an open case involving you. Do you have an open CPS case?: No Check No if there is no open CPS case involving you. Caseworker's Name Write the name of your CPS caseworker if you have one. Phone Number Write the phone number for your CPS caseworker. Is there a CPS Safety Plan in place?: Yes Check Yes if CPS has set up a safety plan for your family. Is there a CPS Safety Plan in place?: No Check No if there is no CPS safety plan. Please list a safe exchange location: Name a safe public place to hand off the children, like a police station open 24 hours. Name Write the full name of the first child or person who lives with you. Relationship to YOU Explain how this person is related to you, such as son, daughter, or roommate. DOB Enter the month, day, and year this person was born. Age Write how old this person is right now. School / Daycare Name Write the name of the school or daycare this person attends, if any. Address Write the street address of the school or daycare. IS THIS ADDRESS CONFIDENTIAL? YES / NO Check yes if this address must be kept private for safety reasons. Has this person been assaulted / threatened OR witnessed violence? Check yes if this person was hurt, threatened, or saw violence happen. Include this person on the protective order? Check yes if you want this person protected by the court order. Name Write the full name of the second child or person who lives with you. Relationship to YOU Explain how this person is related to you, such as son, daughter, or roommate. DOB Enter the month, day, and year this person was born. Age Write how old this person is right now. School / Daycare Name Write the name of the school or daycare this person attends, if any. Address Write the street address of the school or daycare. IS THIS ADDRESS CONFIDENTIAL? YES / NO Check yes if this address must be kept private for safety reasons. Has this person been assaulted / threatened OR witnessed violence? Check yes if this person was hurt, threatened, or saw violence happen. Include this person on the protective order? Check yes if you want this person protected by the court order. Name Write the full name of the third child or person who lives with you. Relationship to YOU Explain how this person is related to you, such as son, daughter, or roommate. DOB Enter the month, day, and year this person was born. Age Write how old this person is right now. School / Daycare Name Write the name of the school or daycare this person attends, if any. Address Write the street address of the school or daycare. IS THIS ADDRESS CONFIDENTIAL? YES / NO Check yes if this address must be kept private for safety reasons. Has this person been assaulted / threatened OR witnessed violence? Check yes if this person was hurt, threatened, or saw violence happen. Include this person on the protective order? Check yes if you want this person protected by the court order. Name Write the full name of the fourth child or person who lives with you. Relationship to YOU Explain how this person is related to you, such as son, daughter, or roommate. DOB Enter the month, day, and year this person was born. Age Write how old this person is right now. School / Daycare Name Write the name of the school or daycare this person attends, if any. Address Write the street address of the school or daycare. IS THIS ADDRESS CONFIDENTIAL? YES / NO Check yes if this address must be kept private for safety reasons. Has this person been assaulted / threatened OR witnessed violence? Check yes if this person was hurt, threatened, or saw violence happen. Include this person on the protective order? Check yes if you want this person protected by the court order. Name Write the full name of the fifth child or person who lives with you. Relationship to YOU Explain how this person is related to you, such as son, daughter, or roommate. DOB Enter the month, day, and year this person was born. Age Write how old this person is right now. School / Daycare Name Write the name of the school or daycare this person attends, if any. Address Write the street address of the school or daycare. IS THIS ADDRESS CONFIDENTIAL? YES / NO Check yes if this address must be kept private for safety reasons. Has this person been assaulted / threatened OR witnessed violence? Check yes if this person was hurt, threatened, or saw violence happen. Include this person on the protective order? Check yes if you want this person protected by the court order. Name Write the full name of the sixth child or person who lives with you. Relationship to YOU Explain how this person is related to you, such as son, daughter, or roommate. DOB Enter the month, day, and year this person was born. Age Write how old this person is right now. School / Daycare Name Write the name of the school or daycare this person attends, if any. Address Write the street address of the school or daycare. IS THIS ADDRESS CONFIDENTIAL? YES / NO Check yes if this address must be kept private for safety reasons. Has this person been assaulted / threatened OR witnessed violence? Check yes if this person was hurt, threatened, or saw violence happen. Include this person on the protective order? Check yes if you want this person protected by the court order.

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