IN THE TRIBAL DISTRICT COURT FOR THE KICKAPOO TRIBE OF OKLAHOMA P.O. BOX 95, MCLOUD, OKLAHOMA

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1 IN THE TRIBAL DISTRICT COURT FOR THE KICKAPOO TRIBE OF OKLAHOMA P.O. BOX 95, MCLOUD, OKLAHOMA, ) Plaintiff, ) ) v. ) Case No.: ), ) Defendant. ) Plaintiff, being sworn, states: 1. (Check one or more) PETITION FOR PROTECTIVE ORDER The defendant caused or attempted to cause serious physical harm to The defendant threatened with Imminent serious physical harm. The defendant has stalked or harassed 2. The incident causing the filing of this petition occurred on or about. (Describe what happened) (If more space is required, attach additional sheets) 1

2 3. The victim and the defendant are related as follows: married divorced parent and child persons related by blood person related by marriage not related present spouse of an ex-spouse persons living in the same household persons formerly living in the same household biological parents of the same child 4. (Answer this question only if the plaintiff is filing on behalf of someone else, minor or incompetent) The plaintiff and the victim are related as follows: married divorced parent and child persons related by blood person related by marriage not related present spouse of an ex-spouse persons living in the same household persons formerly living in the same household biological parents of the same child 5. (Check A or B) A. The victim is in immediate and present danger of abuse from the defendant and an Emergency ex parte order is necessary to protect the victim from serious harm. The plaintiff requests the following relief in the emergency ex parte order: (check one or more) order the defendant not to abuse or injure the victim order the defendant not to visit, assault, molest or otherwise interfere with the victim. order the defendant not to threaten the victim order the defendant to cease stalking the victim order the defendant to cease harassment of the victim order the defendant to leave the residence located at on or before. order the defendant who is a minor child to leave the residence located at by immediately placing the Defendant in the temporary custody of the Department of Human Services. Circle age of defendant: 13, 14, 15, 16, 17 years. (Describe other relief that plaintiff requests) B. The plaintiff does not request an emergency ex parte order. 6. Plaintiff requests the following order to be made by the court following notice to the defendant and a hearing: (Check one or more) order the defendant not to abuse or injure the victim. order the defendant not to visit, assault, molest or otherwise interfere with the victim. 2

3 order the defendant not to threaten the victim. order the defendant to cease stalking the victim. order the defendant to cease harassment of the victim. order the defendant to leave the residence located at on or before. order the defendant who is a minor child to leave the residence located at by immediately placing the defendant in the temporary custody of the Department of Human Services. Circle age of defendant: 13, 14, 15, 16, 17 years of age. (Describe other relief that plaintiff requests) order the defendant to pay attorney fees of the plaintiff in the sum of on or before. order the defendant to pay Court cost of this action in the sum of on or before. 7. Victim is a resident of the Kickapoo jurisdiction wherein this petition is filed. Defendant is a resident of the Kickapoo jurisdiction wherein this petition is filed. 8. Plaintiff has stated the truth, the whole truth and nothing but the truth in this petition. Witness my hand and seal, affixed on the day of, 20. Court Clerk BY: Deputy Court Clerk OATH Before me,, a Notary Public in and for County, State of Oklahoma, personally appeared and he/she being first duly sworn (or affirmed) by me upon his/her oath, says that the facts alleged in the foregoing instrument are true. SEAL Notary Public My Commission Expires: 3

4 Kickapoo Tribal District Court Protective Order Contact Information Today s Date: Plaintiff s Nam: D.O.B. Sex: M/F Age: Social Security#: Are you an enrolled tribal member: yes/no If answer is yes, which tribe: Contact Address: Phone #: Other Contact #: Are child(ren) an enrolled tribal member: yes/no if answer is yes, please state which tribe for each child Name of child D.O.B. Age Sex Tribe/Race Defendant s Name: D.O.B.: Sex: M/F Age: Social Security #: Tatoos: Yes/No Height: Weight: Eye color: Hair Color: Is Defendant an enrolled tribal member? Yes/No If answer is yes, which tribe: Contact address for Defendant: Is Defendant employed? Yes or no if answer is yes, proved name of employer: Employer s address if known: Defendant s phone number: Work #: Court: Provide copy to KTO Police, Behavioral Health, Family Violence Program 4

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