Form JD-FM-137 "Application for Relief From Abuse" - Connecticut

What Is Form JD-FM-137?

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 January 1, 2018;
  • 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-FM-137 by clicking the link below or browse more documents and templates provided by the Connecticut Superior Court.

ADVERTISEMENT
ADVERTISEMENT

Download Form JD-FM-137 "Application for Relief From Abuse" - Connecticut

768 times
Rate (4.8 / 5) 38 votes
APPLICATION FOR
COURT USE ONLY
STATE OF CONNECTICUT
RELIEF FROM ABUSE
SUPERIOR COURT
APPRFA
JD-FM-137 Rev. 1-18
www.jud.ct.gov
C.G.S. §§ 29-28, 29-32, 29-33, 46b-15, 52-231a;
*APPRFA*
P.A. 17-163
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the Americans with
Disabilities Act (ADA). If you need a reasonable accommodation in accordance with
the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
Judicial District of
Court location (number, street, town, zip code)
Docket number
Your name (Applicant) (Last, first, middle initial)
Date of birth (mm/dd/yyyy)
Sex (M/F)
Race
Your mailing address (Number, street)* (See Note below)
Town
State
Zip Code
Your home/residence address* (See Note below)
Same as mailing address
Town
State
Zip Code
Your work address* (See Note below)
Town
State
Zip Code
*Note: Any addresses you provide will be included in the court file and will be provided to the Respondent. These addresses will also
tell the court which law enforcement agencies must be notified if the court issues a restraining order. If you believe that giving
out your home, work, or school address would put you and/or your children's health, safety or liberty in danger, you may use a
mailing address that is different from your home or work address, including the address for the Safe at Home address
confidentiality program, if applicable, but it is important to note that doing so may limit which law enforcement agencies receive
notice of the order. You may also file a Request for Nondisclosure of Location Information form JD-FM-188 (which requires a
mailing address) with the Clerk's Office.
Information About the Respondent (Person the application is filed against)
Respondent's name (Last, first, middle initial)
Date of birth (mm/dd/yyyy)
Sex (M/F)
Race
Respondent's address (Number, street)
(Town)
(State)
(Zip Code)
Respondent's telephone number
Other identifiers (Examples include height, weight and approximate age)
Respondent is ("X" all that apply)
My spouse or a person I have a civil union with
A person who is also the parent of my dependent child or
children in common and we all live together.
If you are seeking additional orders of maintenance, check here
If you are seeking additional orders of maintenance, check here
(If you check this box, you must complete JD-FM-233,
Request for Orders of Maintenance and submit it as part of
(If you check this box, you must complete JD-FM-233, Request for
your application)
Orders of Maintenance and submit it as part of your application)
A person related to me by blood or marriage
Someone I have cohabited with as an intimate partner
A person I reside or resided with
(romantic, spousal, or sexual relationship while living together)
A caretaker who is providing shelter in his or her residence to a
Parent of my child
person 60 years of age or older
My parent
My child
A person I have (or recently had) a dating relationship with
"X" here if you know about any other Protective Order or Restraining Order that exists involving you or the Respondent.
(Give the docket number and court location, if known)
Docket number
Court location
"X" here if a dissolution of marriage (divorce), dissolution of civil union, custody or visitation action exists involving you and the Respondent.
(Give the docket number and court location, if known)
Docket number
Court location
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 relief from abuse hearing, contact the Clerk's Office or the Court Service
Center in the court where your hearing is scheduled.
Page 1 of 2 (continued on page 2)
Print Form
Reset Form
APPLICATION FOR
COURT USE ONLY
STATE OF CONNECTICUT
RELIEF FROM ABUSE
SUPERIOR COURT
APPRFA
JD-FM-137 Rev. 1-18
www.jud.ct.gov
C.G.S. §§ 29-28, 29-32, 29-33, 46b-15, 52-231a;
*APPRFA*
P.A. 17-163
ADA NOTICE
The Judicial Branch of the State of Connecticut complies with the Americans with
Disabilities Act (ADA). If you need a reasonable accommodation in accordance with
the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
Judicial District of
Court location (number, street, town, zip code)
Docket number
Your name (Applicant) (Last, first, middle initial)
Date of birth (mm/dd/yyyy)
Sex (M/F)
Race
Your mailing address (Number, street)* (See Note below)
Town
State
Zip Code
Your home/residence address* (See Note below)
Same as mailing address
Town
State
Zip Code
Your work address* (See Note below)
Town
State
Zip Code
*Note: Any addresses you provide will be included in the court file and will be provided to the Respondent. These addresses will also
tell the court which law enforcement agencies must be notified if the court issues a restraining order. If you believe that giving
out your home, work, or school address would put you and/or your children's health, safety or liberty in danger, you may use a
mailing address that is different from your home or work address, including the address for the Safe at Home address
confidentiality program, if applicable, but it is important to note that doing so may limit which law enforcement agencies receive
notice of the order. You may also file a Request for Nondisclosure of Location Information form JD-FM-188 (which requires a
mailing address) with the Clerk's Office.
Information About the Respondent (Person the application is filed against)
Respondent's name (Last, first, middle initial)
Date of birth (mm/dd/yyyy)
Sex (M/F)
Race
Respondent's address (Number, street)
(Town)
(State)
(Zip Code)
Respondent's telephone number
Other identifiers (Examples include height, weight and approximate age)
Respondent is ("X" all that apply)
My spouse or a person I have a civil union with
A person who is also the parent of my dependent child or
children in common and we all live together.
If you are seeking additional orders of maintenance, check here
If you are seeking additional orders of maintenance, check here
(If you check this box, you must complete JD-FM-233,
Request for Orders of Maintenance and submit it as part of
(If you check this box, you must complete JD-FM-233, Request for
your application)
Orders of Maintenance and submit it as part of your application)
A person related to me by blood or marriage
Someone I have cohabited with as an intimate partner
A person I reside or resided with
(romantic, spousal, or sexual relationship while living together)
A caretaker who is providing shelter in his or her residence to a
Parent of my child
person 60 years of age or older
My parent
My child
A person I have (or recently had) a dating relationship with
"X" here if you know about any other Protective Order or Restraining Order that exists involving you or the Respondent.
(Give the docket number and court location, if known)
Docket number
Court location
"X" here if a dissolution of marriage (divorce), dissolution of civil union, custody or visitation action exists involving you and the Respondent.
(Give the docket number and court location, if known)
Docket number
Court location
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 relief from abuse hearing, contact the Clerk's Office or the Court Service
Center in the court where your hearing is scheduled.
Page 1 of 2 (continued on page 2)
Print Form
Reset Form
Applicant's name
Respondent's name
Docket number
Application For Relief From Abuse
I have been subjected to a continuous threat of present physical pain or physical injury, stalking or a pattern of threatening, by
the Respondent named above as explained more fully in my attached Affidavit.
1. I ask 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 may return to the home one time with police to retrieve belongings. (CT14)
CT14
If I have moved out of the home of the Respondent, the Respondent shall permit me to return to the Respondent's home on one
CT15
occasion, with police, to retrieve my belongings. (CT15)
The Respondent stay 100 yards away from me. (CT16)
CT16
That the order protect my minor children. (CT19)
CT19
Sex
Date of birth
Name
Sex
Date of birth
Name
(Last, first, middle initial)
(M/F)
(mm/dd/yyyy)
(Last, first, middle initial)
(M/F)
(mm/dd/yyyy)
1
4
2
5
6
3
That the order protect animals owned or kept by me. (CT31)
CT31
2. I ask that the court make the following temporary child custody and visitation orders:
Award me temporary custody of the following minor child(ren) who is (are) also the child(ren) of the Respondent.
CT20
Sex
Date of birth
Name
Sex
Date of birth
Name
(Last, first, middle initial)
(M/F)
(mm/dd/yyyy)
(Last, first, middle initial)
(M/F)
(mm/dd/yyyy)
1
4
2
5
6
3
With visitation as follows:
CT21
Without visitation rights to the Respondent.
CT22
3. I ask that the court order the following: (further order)
4. I am in school and I ask that a copy of the restraining 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
5. My minor child or children for whom I am also asking for protection is/are in school and I ask that a copy of the restraining
order, if it is granted, be sent to my child's or children's school (attach additional sheets if necessary).
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)
6. I ask that the court order Ex Parte (immediate) relief because I believe there is an immediate and present physical
danger to me and/or my minor children and/or animals owned or kept by me.
Signature
Print name of person signing
I certify that the statements above are true
to the best of my knowledge and belief.
Subscribed and sworn to before me (Assistant Clerk, Commissioner of Superior Court, Notary Public)
Date signed
JD-FM-137 Rev. 1-18
Page 2 of 2
Print Form
Reset Form
Page of 2