Form JD-CV-143 "Application for Civil Protection Order" - Connecticut

What Is Form JD-CV-143?

This is a legal form that was released by the Connecticut Superior Court - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2017;
  • The latest edition provided by the Connecticut Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-CV-143 by clicking the link below or browse more documents and templates provided by the Connecticut Superior Court.

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Download Form JD-CV-143 "Application for Civil Protection Order" - Connecticut

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APPLICATION FOR
ADA NOTICE
STATE OF CONNECTICUT
CIVIL PROTECTION ORDER
SUPERIOR COURT
The
Judicial
Branch
of
the
State
JD-CV-143 Rev. 10-17
of Connecticut complies with the Americans
www.jud.ct.gov
C.G.S. §§ 6-32, 29-28, 29-32, 29-33, 29-36i, 29-36k
with Disabilities Act (ADA). If you need a
46b-15, 46b-16a, 46b-38a, 51-5c, 53a-107, 53a-223;
reasonable accommodation in accordance
with the ADA, contact a court clerk or an ADA
contact person listed at www.jud.ct.gov/ADA.
Instructions To Person Filing Application (Applicant):
1. Fill out on-line, or print clearly in ink, or use a typewriter. You must also fill out an Affidavit - Civil Protection Order (form JD-CV-144).
Give both forms to the Clerk of Court.
2. If the applicant is under 18 years of age, the Application must be signed and filed by an adult representative, also known as a "next friend". The next friend may be a
parent, guardian or other responsible adult. The attached Affidavit (form JD-CV-144) must be completed by the applicant even if they are under 18 years of age and
represented by a next friend.
3. After your Application and Affidavit are processed, the clerk will give you the proper papers to have served on (delivered to) the respondent (person the application is
filed against).
4. Make sure the originals are returned to court after they are served on the respondent.
Instructions To Clerk:
1. If Ex Parte relief is ordered, prepare the following forms: Order of Protection (form JD-CL-99); Additional Civil Protection Orders (form JD-CL-131) (If applicable);
Order for and Notice of Court Hearing, Return of Service - Civil Protection Order (form JD-CV-145); General Notifications - Civil Protection Order (form JD-CL-129).
2. If the Court orders a hearing, prepare an Order for Notice of Court Hearing, Return of Service - Civil Protection Order (form JD-CV-145).
3. Provide the applicant with the original and three copies of the Application and Affidavit and three copies of any completed order form identified in instruction 1.
4. Retain copies of each for the court file.
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)* (See NOTE below)
(Town)
(State)
(Zip Code)
Home/residence address* (See NOTE below)
Same as mailing address
(Town)
(State)
(Zip Code)
Work address* (See NOTE below)
(Town)
(State)
(Zip Code)
Next friend address (town, state, Zip)* (See NOTE below)
Name of next friend (Last, first, middle initial) (if applicant is a minor)
*NOTE: All addresses provided in this application will be included on papers that are in the court file and will be provided to the respondent. The
applicant's address or addresses will determine which law enforcement agencies are notified if a Civil Protection Order is granted. If you attest
that disclosure of your location information would jeopardize you or your children's health, safety or liberty, you may request that your location
information not be disclosed by completing a Request of Nondisclosure of Location Information - Civil Protection Order (form JD-CV-163).
Information About The Respondent
(Person the application is filed against)
Name of respondent (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)
If yes, how do you know the Respondent:
Do you know the respondent?
Yes
No
Is the respondent a member of your family or household?
Yes
No
A member of
• Your spouse or a person you have a civil union with
• Someone you have cohabited with as an intimate partner
your family or
(romantic, spousal, or sexual relationship while living together)
• Your former spouse or a person you had a civil union with
household is
• The parent of your child
• A person related to you by blood or marriage
defined as:
• Your parent
• A person you reside or resided with
• Your child
• A person you have (or recently had) a dating relationship with
NOTE: If the respondent in your case is a family or household member, you DO NOT qualify for a Civil Protection Order and you
should NOT continue to fill out this form. However, if the respondent is a family or household member you may qualify for an
Order of Relief from Abuse under section 46b-15 of the Connecticut General Statutes. For more information, see Civil Protection
Order Information Form (form JD-CV-148), and Restraining Orders: How to Apply for Relief from Abuse (form JDP-FM-142).
"X" here if a Criminal Protective Order or Family Restraining Order exists affecting any party to this Application.
(Enter docket number and court location)
Docket number
Court location
Page 1 of 2 (continued on page 2)
Print Form
Reset Form
APPLICATION FOR
ADA NOTICE
STATE OF CONNECTICUT
CIVIL PROTECTION ORDER
SUPERIOR COURT
The
Judicial
Branch
of
the
State
JD-CV-143 Rev. 10-17
of Connecticut complies with the Americans
www.jud.ct.gov
C.G.S. §§ 6-32, 29-28, 29-32, 29-33, 29-36i, 29-36k
with Disabilities Act (ADA). If you need a
46b-15, 46b-16a, 46b-38a, 51-5c, 53a-107, 53a-223;
reasonable accommodation in accordance
with the ADA, contact a court clerk or an ADA
contact person listed at www.jud.ct.gov/ADA.
Instructions To Person Filing Application (Applicant):
1. Fill out on-line, or print clearly in ink, or use a typewriter. You must also fill out an Affidavit - Civil Protection Order (form JD-CV-144).
Give both forms to the Clerk of Court.
2. If the applicant is under 18 years of age, the Application must be signed and filed by an adult representative, also known as a "next friend". The next friend may be a
parent, guardian or other responsible adult. The attached Affidavit (form JD-CV-144) must be completed by the applicant even if they are under 18 years of age and
represented by a next friend.
3. After your Application and Affidavit are processed, the clerk will give you the proper papers to have served on (delivered to) the respondent (person the application is
filed against).
4. Make sure the originals are returned to court after they are served on the respondent.
Instructions To Clerk:
1. If Ex Parte relief is ordered, prepare the following forms: Order of Protection (form JD-CL-99); Additional Civil Protection Orders (form JD-CL-131) (If applicable);
Order for and Notice of Court Hearing, Return of Service - Civil Protection Order (form JD-CV-145); General Notifications - Civil Protection Order (form JD-CL-129).
2. If the Court orders a hearing, prepare an Order for Notice of Court Hearing, Return of Service - Civil Protection Order (form JD-CV-145).
3. Provide the applicant with the original and three copies of the Application and Affidavit and three copies of any completed order form identified in instruction 1.
4. Retain copies of each for the court file.
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)* (See NOTE below)
(Town)
(State)
(Zip Code)
Home/residence address* (See NOTE below)
Same as mailing address
(Town)
(State)
(Zip Code)
Work address* (See NOTE below)
(Town)
(State)
(Zip Code)
Next friend address (town, state, Zip)* (See NOTE below)
Name of next friend (Last, first, middle initial) (if applicant is a minor)
*NOTE: All addresses provided in this application will be included on papers that are in the court file and will be provided to the respondent. The
applicant's address or addresses will determine which law enforcement agencies are notified if a Civil Protection Order is granted. If you attest
that disclosure of your location information would jeopardize you or your children's health, safety or liberty, you may request that your location
information not be disclosed by completing a Request of Nondisclosure of Location Information - Civil Protection Order (form JD-CV-163).
Information About The Respondent
(Person the application is filed against)
Name of respondent (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)
If yes, how do you know the Respondent:
Do you know the respondent?
Yes
No
Is the respondent a member of your family or household?
Yes
No
A member of
• Your spouse or a person you have a civil union with
• Someone you have cohabited with as an intimate partner
your family or
(romantic, spousal, or sexual relationship while living together)
• Your former spouse or a person you had a civil union with
household is
• The parent of your child
• A person related to you by blood or marriage
defined as:
• Your parent
• A person you reside or resided with
• Your child
• A person you have (or recently had) a dating relationship with
NOTE: If the respondent in your case is a family or household member, you DO NOT qualify for a Civil Protection Order and you
should NOT continue to fill out this form. However, if the respondent is a family or household member you may qualify for an
Order of Relief from Abuse under section 46b-15 of the Connecticut General Statutes. For more information, see Civil Protection
Order Information Form (form JD-CV-148), and Restraining Orders: How to Apply for Relief from Abuse (form JDP-FM-142).
"X" here if a Criminal Protective Order or Family Restraining Order exists affecting any party to this Application.
(Enter docket number and court location)
Docket number
Court location
Page 1 of 2 (continued on page 2)
Print Form
Reset Form
Name of applicant
Name of respondent
Docket number
Application For Civil Protection Order
1. I have been the victim of one or more of the following by the respondent named above as explained more fully in my
Off
attached Affidavit: ("X" all that apply)
Sexual Abuse
Sexual Assault
Stalking (defined as two or more willful acts, performed in a threatening, predatory or disturbing manner of: Harassing, following, lying in wait for,
surveilling, monitoring or sending unwanted gifts or messages to another person directly, indirectly or through a third person, by any method,
device or other means, that causes such person to reasonably fear for his or her physical safety)
2. I have not obtained any other court order because of such sexual abuse, sexual assault or stalking.
3. The respondent is not a member of my family or household as defined in the Instructions and Information About the
Respondent sections of this form. See sections 46b-15 and 46b-38 of the Connecticut General Statutes or the Civil
Off
Protection Order Information Form (form JD-CV-148) for more information.
4. I request that the court order the following conditions: ("X" all that apply)
The respondent not assault, threaten, abuse, harass, follow, interfere with, or stalk me. (CT01)
CT01
The respondent stay away from my home or wherever I shall reside. (CT03)
CT03
The respondent not contact me in any manner, including by written, electronic or telephone contact, and not contact my home,
CT05
workplace or others with whom the contact would be likely to cause annoyance or alarm to me. (CT05)
The respondent stay 100 yards away from me. (CT16)
CT16
5. I request that the court order the following other conditions:
6. I am in school and I request that a copy of the Civil Protection Order, if it is granted, be sent to my school
Name of school
Fax number of school
Address of school (Number, street)
(Town)
(State)
(Zip code)
Request For Ex Parte (Immediate) Relief ("X" if this applies)
7. I request that the court order Ex Parte (immediate) relief because I believe I am in imminent danger.
Date signed
Signed (Applicant or next friend, if applicant is a minor)
Signed (Clerk, Notary, Commissioner of Superior Court)
Subscribed and
u
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? ……………………
Yes
No
Unknown
2. Does the respondent hold an eligibility certificate for a pistol or revolver, a long gun
eligibility certificate, or an ammunition certificate? ………………………………………
Yes
No
Unknown
3. Does the respondent possess one or more firearms? …………………………………
Yes
No
Unknown
4. Does the respondent possess ammunition? ……………………………………………
Yes
No
Unknown
If you think you need more security when you are in court for your Civil Protection Order hearing, contact the Clerk's Office or the
Court Service Center in the court where your hearing is scheduled.
Order
Having reviewed the application and affidavit, the court finds:
The allegations in the affidavit do not meet the requirements of section 46b-16a(a) of the Connecticut General Statutes and the
application is denied.
The allegations of the affidavit meet the requirements of section 46b-16a(a) of the Connecticut General Statutes and a hearing is
scheduled. See Order for and Notice of Court Hearing, Return of Service - Civil Protection Order (form JD-CV-145).
There are reasonable grounds to believe that an imminent danger exists to the applicant. Ex parte relief is ordered and a hearing is
scheduled. See Order of Protection (form JD-CL-99), Additional Civil Protection Orders (form JD-CL-131), if applicable, and Order for
and Notice of Court Hearing, Return of Service - Civil Protection Order (form JD-CV-145).
There are reasonable grounds to believe that the respondent engaged in the use, attempted use or threat of physical force.
The respondent is ordered to surrender or transfer all firearms or ammunition.
By the Court (Print or Type Name of Judge)
On (Date)
Signed (Judge, Clerk)
Date signed
JD-CV-143 Rev. 10-17
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