Under oath, I petition the Court for a temporary restraining order and injunction against the Respondent under Section 1.13(G) of the Stockbridge-Munsee Community Ordinances, Chapter 1, based upon the following:

1. Our residences/premises are stated as above.
2. The Respondent has harassed me by doing the following: (Mark all that apply)
       Striking, shoving, kicking, or otherwise subjecting me to physical contact or physical harm, or attempting to do the same.
       Engaging in a course of conduct or repeatedly committing acts which harass or intimidate me and which serve no legitimate purpose.
       Engaging in a course of conduct that evidences a credible threat against me.
3. Attached as a part of this petition is a statement of facts indicating that Respondent has harassed or attempted to harass me.

I REQUEST THAT THE COURT: (Mark all that apply)
              Immediately issue a temporary restraining order and set a time for a hearing on an injunction requiring the Respondent to:
                            Refrain from harassing me.
                            Refrain from contacting me and causing any other person to have contact with me.
              Set a time for a hearing on the Petition for an injunction.
              Enter an injunction for two years and or up to 5 years based on the discretion of the Court:
              Notify Stockbridge-Munsee and other law enforcement that this Petition has been filed and provide them with a copy.

Signature of Petitioner:     
Date: