Civil Protection Order Petition

PETITION FOR A DOMESTIC VIOLENCE CIVIL PROTECTION ORDER
Disclaimer:

This form is designed as a self-help tool so a domestic violence victim can file a court petition for a Civil Protection Order without a lawyer. Fill in the answers to the best of your ability, and if you are not sure about an answer you can leave it blank. A High Court clerk will assist you with the CPO petition when you take it to the courthouse. Please note that although American Samoa Legal Aid (ASLA) created this tool, filling it out does not create an attorney-client relationship with ASLA. If you want ASLA to represent you, you will need to complete the ASLA client eligibility intake interview process including executing a Retainer Agreement with ASLA.

When you are done filling out this form, you will be ready to print it out and file it with a High Court clerk at Fagatogo. Remember to sign your name at the bottom of the last page on the line that says "Petitioner"! The High Court clerk will notarize and help you file your CPO petition.

We understand what a difficult position you are in. If you ever wish to speak to us directly, you can call us at 633-3300 or 633-3301, email us at asla@aslegalaid.org, message us on facebook at https://www.facebook.com/AmericanSamoaLegalAid, or contact us through our website at https://www.aslegalaid.org.

Your Basic Information
Your Full Name
This name should match what appears on your ID.
Address

Mailing Address or PO Box

Street Address Line 2

Home Village State / Territory

Zip Code
The Perpetrator's Basic Information

Throughout this form we will be using the word "perpetrator" to refer to the person you want protection from and who has hurt you. If you don't know the answers to the questions below, feel free to leave them blank for now.
Perpetrator's Full Name
This should match what appears on their ID.
Perpetrator's Address

Mailing Address or PO Box

Street Address Line 2

Home Village State / Territory

Zip Code
Perpetrator's Social Security Number
Perpetrator's Date of Birth

Month Day Year
Date

Names and Information of Family/Household Members Seeking Protection

Please type the information for each additional person you wish to be covered by this protection order
Family/Household Member #1
Full Name
This should match what appears on their ID
Date of Birth

Month Day Year
Date
Relationship to Perpetrator
For example: ''son,'' ''daughter,'' or ''niece.''
Relationship to You
For example: ''son,'' ''daughter,'' or ''niece.''
Who Do They Live With?
List the relative's name and their relationship to the person who will get protection. For example: ''Mary Tanoa (cousin)''
Family/Household Member #2
Full Name
This should match what appears on their ID
Date of Birth

Month Day Year
Date
Relationship to Perpetrator
For example: ''son,'' ''daughter,'' or ''niece.''
Relationship to You
For example: ''son,'' ''daughter,'' or ''niece.''
Who Do They Live With?
List the relative's name and their relationship to the person who will get protection. For example: ''Mary Tanoa (cousin)''
Family/Household Member #3
Full Name
This should match what appears on their ID
Date of Birth

Month Day Year
Date
Relationship to Perpetrator
For example: ''son,'' ''daughter,'' or ''niece.''
Relationship to You
For example: ''son,'' ''daughter,'' or ''niece.''
Who Do They Live With?
List the relative's name and their relationship to the person who will get protection. For example: ''Mary Tanoa (cousin)''
Family/Household Member #4
Full Name
This should match what appears on their ID
Date of Birth

Month Day Year
Date
Relationship to Perpetrator
For example: ''son,'' ''daughter,'' or ''niece.''
Relationship to You
For example: ''son,'' ''daughter,'' or ''niece.''
Who Do They Live With?
List the relative's name and their relationship to the person who will get protection. For example: ''Mary Tanoa (cousin)''
Family/Household Member #5
Full Name
This should match what appears on their ID
Date of Birth

Month Day Year
Date
Relationship to Perpetrator
For example: ''son,'' ''daughter,'' or ''niece.''
Relationship to You
For example: ''son,'' ''daughter,'' or ''niece.''
Who Do They Live With?
List the relative's name and their relationship to the person who will get protection. For example: ''Mary Tanoa (cousin)''
Family/Household Member #6
Full Name
This should match what appears on their ID
Date of Birth

Month Day Year
Date
Relationship to Perpetrator
For example: ''son,'' ''daughter,'' or ''niece.''
Relationship to You
For example: ''son,'' ''daughter,'' or ''niece.''
Who Do They Live With?
List the relative's name and their relationship to the person who will get protection. For example: ''Mary Tanoa (cousin)''

Describe the acts of domestic violence the perpetrator has engaged in. Please be specific about the nature and extent of the abuse. This will explain to the Judge why you need help. Take your time to explain fully, and include details and dates when possible. If you need more space, you can print your answer on another sheet of paper and bring it with you to court along with this petition.
(Some examples of domestic violence are: beating you, hurting your children, threatening you, forcing you to engage in sexual behavior against your will, or other controlling behavior.)

Case History
Do you have another current or past case that involves you, the perpetrator, and any of the family or household members you've listed in this petition? This includes cases like a prior protection order, a criminal case like a peace disturbance or domestic violence offense, a divorce, or a child support or custody case.

Yes No
Please list the case name, number, and court or county of each case:
Case #1
Case Name
Case Number
Court or County of the Case
Case #2
Case Name
Case Number
Court or County of the Case
Case #3
Case Name
Case Number
Court or County of the Case
Case #4
Case Name
Case Number
Court or County of the Case
Should be Empty:

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PETITION FOR A DOMESTIC VIOLENCE CIVIL PROTECTION ORDER

Your Basic Information

The Perpetrator's Basic Information

Check All Boxes That Apply to You

Check All Boxes That Apply to You

Case History

Case #1

Case #2

Case #3

Case #4