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Lucas County Domestic Relations Court Domestic Violence Information
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This form has been modified since it was saved. Please review all fields before submitting.
Petitioner (You)
*
Respondent
*
E-mail address
*
Date of Birth
*
Date of Birth
Relationship to you
*
Address
*
City
*
State
*
Zip
*
Phone
*
Race
*
Petitioner Information:
Attorney
*
Employment
*
Dates you lived together? (Start Date - End Date)
*
Who referred you to us?
Have you filed for domestic violence before?
*
-- Select One --
Yes
No
If yes, where?
Do you have a Temporary Protection Order?
*
-- Select One --
Yes
No
Do you have a Civil Protection Order?
*
-- Select One --
Yes
No
Is there a divorce / dissolution pending?
*
-- Select One --
Yes
No
Planned
NA
Has Children Services ever been involved with your family?
*
-- Select One --
Yes
No
If yes, what year(s)?
Caseworker
Incident
Date of incident
*
Date of incident
Brief description
*
If there were children in the home, where were they?
Did you have medical attention?
*
-- Select One --
Yes
No
If yes, where?
Where the police called?
*
-- Select One --
Yes
No
If yes, was the Respondent arrested?
-- Select One --
Yes
No
If yes, where you arrested?
-- Select One --
Yes
No
Did you sign a complaint against the Respondent?
*
-- Select One --
Yes
No
Lis any PAST medical treatment for injuries
Describe the history of domestic violence in this relationship and arrests during the past year
*
Describe any problems you have had as a result of conflicts with Respondent (for example, utilizes shut off, fired from job, evicted, etc.)
*
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