☐ CIRCUIT COURT ☐ DISTRICT COURT OF MARYLAND FOR
Located at Telephone
Case No.
NOTE: Respondent will be served a copy of this completed document. Petitioner does not need to give an address if doing so risks
further harm, further abuse, or reveals the confidential address of a shelter. If this the case check here
☐.
If you need additional paper, ask the clerk.
Fill in the following, checking the appropriate boxes.
vs.
☐ Petition filed electronically under FL § 4-505.1
PETITION FOR PROTECTION FROM
☐ DOMESTIC VIOLENCE ☐ CHILD ABUSE ☐ VULNERABLE ADULT ABUSE
(Family Law § 4-504)
1. I am ☐ the current or former spouse of the respondent; ☐ a cohabitant of the respondent; ☐ a person related to the
respondent by blood, marriage, or adoption;
☐ a parent, stepparent, child, or stepchild of the respondent or the person
eligible for relief who resides or resided with the respondent or person eligible for relief for at least 90 days within one
(1) year before the filing of the petition;
☐ a vulnerable adult; ☐ an individual who has a child in common with the
respondent;
☐ an individual who has had a sexual relationship with the respondent within one (1) year before the
filing of the petition; or
☐ an individual who alleges that within six (6) months before the filing of the petition the
respondent committed rape or a sexual offense or attempted rape or sexual offense against the individual.
2. I want relief for
☐ myself ☐ minor child ☐ vulnerable adult, from abuse by .
The respondent, whose present whereabouts (if known) are ,
committed the following acts of abuse against
on or about, (check all that apply)
☐ kicking ☐ punching ☐ choking/strangling
☐ slapping ☐ shooting ☐ rape or other sexual offense (or attempt) ☐ hitting with object ☐ stabbing ☐ shoving
☐ threats of violence ☐ mental injury of a child ☐ detaining against will ☐ stalking ☐ biting ☐ revenge porn
☐ other
The details of what happened are:
3. (If the victim is a child or vulnerable adult, fill in the following): I am asking for protection for a
☐ child
☐ vulnerable adult whose name is .
At this time the victim can be found at .
I am
☐ State’s Attorney ☐ DSS ☐ a relative ☐ an adult living in the home.
4. The person(s) I want protected are (include yourself if you are a victim):
Name(s) Birthdate Relationship to Respondent
CC-DC-DV-001 (Rev. 10/2022) Page 1 of 3
PETPR
Home Telephone No.
Work Telephone No.
(Give specific details of what happened, when and where it happened, and any injuries sustained)
Name of alleged abuse
Date
Petitioner
Respondent
Address
Name(s)
Address
City, State, Zip
City, State, Zip
Work Telephone No.
Court Address
Cit
/Count
Home Telephone No.