FAMILY COURT PETITION FOR AN CASE NUMBER

FIRST CIRCUIT ORDER FOR PROTECTION FC-DA No.

STATE OF HAWAI‘I
Petitioner’s name, address, and telephone no.:

PETITIONER
v. and, Petitioner’s Attorney’s name, address, & telephone no.:

RESPONDENT

I. Petitioner alleges, under penalty of perjury, that:

1. This Petition is made pursuant to Hawai‘i Revised Statues (HRS) Chapter 586 and HRS section 134-7.
2. I reside on the island of O‘ahu:
3. ~ and on behalf of the following family or household member(s)
I am submitting this Petition for myself ✘
who is/are ✘ ~ minor(s) or ~ incapacitated adult(s):
Name Sex Year of Birth Legal Mother and Father or Relationship to Petitioner
(if person is a minor) (if person is an adult)

~ Name(s) and species of the animal(s) belonging to household in need of protection, if

~ The incapacitated adult in paragraph # 3 is unable to come to court. If there is a guardianship ordered by a
court, complete the following case information,
Case name: Case number:
Location of court: Type of case:
4. I have the following relationship with the Respondent:
Length of our relationship: day(s) month(s) year(s)
A. ~ we are married.
B. ~
✘ we were married, but are now divorced.
C. ~ we are current or former reciprocal beneficiaries.
D. ~ we are or were dating (romantic, courting, or engaged).
E. ~ we are now living together.
F. ~ we used to live together.
G. ~ we are related by blood and Respondent is my .
H. ~
✘ we have a child/children together. COURT USE ONLY
FC Adm 5/12/16 Petition for an Order for Protection (SELF) 1F-P-752
1 Attachments: Temporary Restraining Order; Notice of Hearing
 FAMILY COURT PETITION FOR AN CASE NUMBER
FIRST CIRCUIT ORDER FOR PROTECTION FC-DA No.
STATE OF HAWAI‘I Page 2
5. The Respondent has abused the Petitioner and/or the minor(s), incapacitated adult(s), and/or pet(s) as follows:
A. FIRST INCIDENT OF ABUSE
Respondent abused ~ me ~
✘ and/or
on (date) by ~ doing or ~ threatening to do this:
✘
~ choke ~ force to have sex ~ grab ~ hit ~ kick ~ slap ~ punch ~ push ~ shove ✘
~ other
briefly describe this incident:

This was: ~ physical harm;

✘ ~ threat of imminent physical harm, bodily injury, assault;
✘
~
✘ extreme psychological abuse; ~ malicious property damage.
The following children were in the home, were close by, or were present when the above incident occurred:

B. MOST RECENT INCIDENT OF ABUSE (check here if same as above ✘ ~)

Respondent abused ~ me ✘ ~ and/or
on (date) ~ doing or ~ threatening to do this:
by ✘
~ choke ~ force to have sex ~ grab ~ hit ~ kick ~ slap ~ punch ~ push ~ shove ✘
~ other
briefly describe this incident:

This was: ~ physical harm;

✘ ~ threat of imminent physical harm, bodily injury, assault;
✘
~ extreme psychological abuse;
✘ ~ malicious property damage.
The following children were in the home, were close by, or were present when the above incident occurred:

C. OTHER INCIDENT(S) OF ABUSE (attach continuation page(s) if needed)

Respondent abused ~ me ~
✘ and/or
on (date) by ~ doing or ~ threatening to do this:
✘
~ choke ~ force to have sex ~ grab ~ hit ~ kick ~ slap ~ punch ~ push ~ shove ~ other
briefly describe this incident:

This was: ~
✘ physical harm; ~ threat of imminent physical harm, bodily injury, assault;
✘
~
✘ extreme psychological abuse; ~ malicious property damage.
The following children were in the home, were close by, or were present when the above incident occurred:

FC Adm 5/12/16 Petition for Order for Protection (SELF) 1F-P-752

Attachments: Temporary Restraining Order; Notice of Hearing
 FAMILY COURT PETITION FOR AN CASE NUMBER
FIRST CIRCUIT ORDER FOR PROTECTION FC-DA No.
STATE OF HAWAI‘I Page 3

6. The Respondent:
~ may be mentally ill.
A. ✘
~ may use illegal drugs.
B. ✘
C. ~ is a member of the Armed Services. ~ is deployed or has received deployment orders.
~ may need supervised visitation with the child(ren) because:
D. ✘

E. ~
✘ may own/possess/have access to a weapon (describe):

7. Firearms (check all that apply and fill in the blanks):

~ owns ✘
A. ✘ ~ possesses ✘ ~ has access to ~ intends to obtain ~ intends to transfer ownership of firearm(s),
which may be used to threaten, injure or abuse a person as follows:
1) Description of firearm(s):

2) Location of firearm(s): (give street address and describe specific place where firearm is located)

B. ~ The Respondent is a member of the police department, a sheriff, a law enforcement officer, a member of
the armed forces of the State of Hawai‘i or the United States, a mail carrier, or is employed by the State
or subdivisions thereof, or the United States, and may be required to be armed while on duty.
8. Other court cases:
I and/or my family and household members and/or the Respondent are or have been involved in other court cases
(check all that apply and list the case number if you know it):
~
✘ Divorce: ~ Paternity:
~ Restraining Order/Protective Order:
~ Juvenile: ~
✘ C.P.S.:
~
✘ Child Support: ~ Criminal:
~ Others:
9. The address I live in is ~ owned ~ rented
✘ by:
10. The social worker, police officer, or other official from this agency told me to file this Petition (identify the agency):

FC Adm 5/12/16 Petition for Order for Protection (SELF) 1F-P-752

Attachments: Temporary Restraining Order; Notice of Hearing
 FAMILY COURT PETITION FOR AN CASE NUMBER
FIRST CIRCUIT ORDER FOR PROTECTION FC-DA No.
STATE OF HAWAI‘I Page 4

II. Based on the foregoing statements and information, Petitioner requests the following:
1. A Temporary Restraining Order enjoining the Respondent and any other person acting on his/her behalf from:
A. contacting, threatening, or physically abusing me and my family and household members (no contact includes
no meetings, email, phone calls, messaging, mail).
B. entering or visiting my residence.
C. maliciously/intentionally damaging my property or the property of my family and household members.
D. psychologically abusing me and my family and household members.
E. ~ contacting, threatening, or physically abusing me at my place of work.
Employer’s name and address:

F. ~
✘ contacting, threatening, or physically abusing the children at school. School names and addresses:

G. ~taking, concealing, removing, threatening, physically abusing, or otherwise disposing of any animal(s)
previously identified in Section I, #3, as belonging to the household.
2. ~ An order requiring Respondent immediately vacate my residence.
3. An order requiring Respondent to appear in court and show cause as to why the Order should not be continued.
4. A Protective Order continuing the Temporary Restraining Order and including:
~ temporary visitation and custody orders.
~ temporary prohibition of visitation with (children’s names):
✘
~ supervised visitation with (children’s names):

to be supervised by: who ~ does not yet know of this request.

~ has agreed to this.
~
✘ requiring the Respondent to participate in domestic violence intervention services and/or counseling:
~
✘
~
✘
5. The Protective Order should last for at least month(s) or year(s).
I HEREBY SOLEMNLY AND SINCERELY DECLARE UNDER PENALTY OF PERJURY THAT THE
STATEMENTS MADE HEREIN ARE TRUE AND CORRECT TO THE BEST OF MY BELIEF,
INFORMATION, AND KNOWLEDGE.
DATED: Kapolei, Hawai‘i: .

Petitioner’s Signature

FC Adm 5/12/16 Petition for Order for Protection (SELF) 1F-P-752

Attachments: Temporary Restraining Order; Notice of Hearing
 FAMILY COURT PETITION FOR AN CASE NUMBER
FIRST CIRCUIT ORDER FOR PROTECTION FC-DA No.
STATE OF HAWAI‘I Attach this page after page two of the Petition
. OTHER INCIDENT(S) OF ABUSE (attach continuation page(s) if needed)
Respondent abused ~ me ✘ ~ and/or .
on (date) ~ doing or ~ threatening to do this:
by ✘
~ choke ~ force to have sex ~ grab ~ hit ~ kick ~ slap ~ punch ~ push ~ shove ~
✘ other
briefly describe this incident:

This was: ~ physical harm; ~ threat of imminent physical harm, bodily injury, assault;
~ extreme psychological abuse; ~ malicious property damage.
✘
These children were in the home, were close by, or were present when the above incident occurred:

. OTHER INCIDENT(S) OF ABUSE (attach continuation page(s) if needed)

Respondent abused ~ me ✘ ~ and/or .
on (date) ~ doing or ~ threatening to do this:
by ✘
~ choke ~ force to have sex ~ grab ~ hit ~ kick ~ slap ~ punch ~ push ~ shove ✘
~ other
briefly describe this incident:

This was: ~
✘ physical harm; ~
✘ threat of imminent physical harm, bodily injury, assault;
~
✘ extreme psychological abuse; ~ malicious property damage.
These children were in the home, were close by, or were present when the above incident occurred:

. OTHER INCIDENT(S) OF ABUSE (attach continuation page(s) if needed)

Respondent abused ~ me ~ ✘ and/or .
on (date) by ~
✘ doing or ~ threatening to do this:
~ choke ~ force to have sex ~ grab ~ hit ~ kick ~ slap ~ punch ~ push ~ shove ~ other
briefly describe this incident:

This was: ~
✘ physical harm; ~ threat of imminent physical harm, bodily injury, assault;
✘
~
✘ extreme psychological abuse; ~ malicious property damage.
These children were in the home, were close by, or were present when the above incident occurred:

FC Adm 5/12/16 Continuation Page for Petition for Order for Protection (SELF) 1F-P-752
Attachments: Temporary Restraining Order; Notice of Hearing
 LEGAL DEFINITIONS
"Dating relationship" means a romantic, courtship, or engagement relationship, often but not necessarily characterized
by actions of an intimate or sexual nature, but does not include a casual acquaintanceship or ordinary fraternization
between persons in a business or social context.

Pursuant to section 586-4(b) of the Hawai‘i Revised Statutes ("HRS"), for any person who is alleged to be
a family or household member by virtue of a dating relationship, the court may consider the following factors in
determining whether a dating relationship exists:
(1) The length of the relationship;
(2) The nature of the relationship; and
(3) The frequency of the interaction between the parties.

"Domestic abuse" means:

(1) Physical harm, bodily injury, assault, or the threat of imminent physical harm, bodily injury, or assault,
extreme psychological abuse or malicious property damage between family or household members; or
(2) Any act which would constitute an offense under HRS section 709-906, or under part V or VI of HRS
chapter 707 committed against a minor family or household member by an adult family or
household member.

"Extreme psychological abuse" means an intentional or knowing course of conduct directed at an individual that
seriously alarms or disturbs consistently or continually bothers the individual, and that serves no legitimate
purpose; provided that such course of conduct would cause a reasonable person
to suffer extreme emotional distress.

"Family or household member" means spouses or reciprocal beneficiaries, former spouses or former reciprocal
beneficiaries, persons who have a child in common, parents, children, persons related by consanguinity, persons
jointly residing or formerly residing in the same dwelling unit, and persons who
have or have had a dating relationship.

"Malicious property damage" means an intentional or knowing damage to the property of another, without his/her
consent, with an intent to thereby cause emotional distress.

In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you
require a reasonable accommodation for a disability, please contact the ADA Coordinator at the First Circuit
Family Court Office by telephone at 954-8200, fax 954-8308, or via email at [email protected]
at least ten (10) working days prior to your hearing or appointment date.

Please call the Family Court TRO Unit at 538-5959 if you have any questions about how to fill out this form
or are in need of an interpreter.

FC Adm 5/1216 Legal Definitions for Petition for Order for Protection (SELF)
1F-P-752