C1A Application Form – Fill Out and Use This PDF

If completing this form by hand, please use black ink and BLOCK CAPITAL LETTERS

You are completing this form because there are allegations that the child(ren) listed in this form may have sufered or be at risk of sufering domestic abuse, violence or harm.

“Domestic violence/abuse” means any incident of threatening behaviour, violence or abuse (psychological, physical, sexual, inancial or emotional) between adults who are or have been intimate partners or family members regardless of gender or sexuality.

The Children Act 1989 deines the following terms as:

“Harm” means ill treatment or damage to health and development, including, for example, damage sufered from seeing or hearing the ill treatment of another.

“Development” means physical, intellectual, emotional, social or behavioural development.

“Health” means physical or mental health.

“Ill-treatment” includes sexual abuse and forms of ill-treatment which are not physical.

Section 1 - About you (the person completing this form)

C1A Allegations of harm and domestic violence (Supplemental information form) (04.11)

© Crown copyright 2011

	Do you have a solicitor	Yes	No
	acting for you?
		If Yes, please give the following details

Your solicitor’s details

Your solicitor’s name

Name of irm

Address

Postcode

Telephone number

Fax number

DX number

Solicitor’s Reference

Section 2 - Details of domestic abuse\violence or harm

In this section outline the nature and frequency of the abuse experienced by you or the child(ren) and if this has led to any involvement with the police, social services, children’s services, your doctor (GP) or any other outside agency(ies). (Provide the details in the table on the page 3).

2

4

Section 4 - Other concerns about your child(ren)

	Do you have any other concerns	Yes	No
	about your child(ren)’s safety and
	wellbeing?	If Yes, please give details

5

Section 5 - Steps or orders required to protect the safety and wellbeing

What steps or orders do you want the court to take or make to protect the safety of the child(ren) and/or yourself?

Non-molestation order: The court may decide to make a non- molestation order under Part IV of the Family Law Act 1996. A non- molestation order requires that the person against who the order has been made may not be violent or threaten violence, harass, pester or annoy the person who applied for the order.

The diferent types of orders that can be applied for under section 8 of the Children Act 1989 are as follows:

Prohibited Steps: this prevents a parent from taking a particular action as set out in the order without the permission of the court. This also applies to actions by any other person named in the order.

Speciic issue: this decides speciic questions e.g. about education, medical treatment or a foreign holiday or visit where parents or those with parental responsibility cannot agree.

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Section 6 - Statement of truth

*[I believe] [The applicant/respondent believes] that the facts stated in this application are true.

*delete as

appropriate *I am duly authorised by the applicant/respondent to sign this statement.

Print full name

Name of solicitors irm

Proceedings for contempt of court may be brought against a person who makes or causes to be made, a false statement in a document veriied by a statement of truth.

Section 7 - Attending court

Please indicate whether you intend to request any special arrangements to be made for you to attend court. The court will make every efort to meet these needs, subject to facilities available. Please telephone the court in advance of the hearing to clarify what arrangements can be made.

Separate Waiting rooms

Separate Exits and Entrances

Screens

Video Links

Separate Toilets

Advance Viewing of the Court

Other

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Checklist

Before sending your forms to the court, please complete this checklist to conirm that you have enclosed the following items:

If you are the applicant - C100 (Application under the Children Act 1989 for a residence, contact or other section 8 order) or if you are the respondent – C7 (Response to an application under the Children Act 1989).

C8 (Conidential contact details)

Note: Only attach this form if you want to withhold your contact details from the other party.

Copies of any orders made by the court for your protection — see section 2.

Any other written evidence which you are able to provide at this stage to support your allegations made in the table on page 3.

If you have any concerns about your safety and that of your children you can call the National Domestic Violence Helpline on

freephone 0808 2000 247 or

you get more information from www.nationaldomesticviolencehelpline.org.uk

If you are a man and have concerns for your safety and that of your children you can call the Men’s Advice Line and Enquiry on

freephone 0808 801 0327 or

you get more information from www.mensadviceline.org.uk

Other organisations that may be able to provide advice for children or young people are:

Childline on freephone 0800 1111 and NSPCC Child Protection Helpline on freephone 0808 800 500

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Response to allegations of harm - To be completed by the person in receipt of this form

You do not have to complete this section unless you wish to comment on any of the information given in this form.

Please give brief comments on the information provided on the table on page 3 of this form. You will have an opportunity to make a more detailed statement later in the proceedings.

1.

2.

3.

4.

5.

Any other comments you have on the information provided in this form

Statement of truth

*[I believe] [The applicant/respondent believes] that the facts stated in this application are true.

*delete as

appropriate *I am duly authorised by the applicant/respondent to sign this statement.

Print full name

Name of solicitors irm

Signed

Dated

/

/

D

D

M

M

Y

Y

Y

Y

(Applicant) (Respondent) (‘s Solicitor)

Position or oice held (If signing on behalf of irm or company)

Proceedings for contempt of court may be brought against a person who makes, or causes to be made, a false statement in a document veriied by a statement of truth.

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Notes for Guidance and Checklist

For Supplemental Information Form C1A

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Section 4

Are there any other concerns you would like to raise regarding your Child(ren)?

This section is for any concerns not already raised in the form regarding the childs safety and wellbeing.

Section 5

Steps or orders required to protect your wellbeing and safety and that of the children

The diferent types of orders that can be applied for under section 8 of the Children Act 1989 are as follows:

a)Prohibited Steps: this prevents a parent from taking a particular action as set out in the order without the permission of the court. This also applies to actions by any other person named in the order.

b)Speciic issue: this decides speciic questions e.g. about education, medical treatment or a foreign holiday or visit where parents or those with parental responsibility cannot agree.

Section 5

Attending the Court

This section asks if you require any special measures put in place when you attend court. The court will try to supply you and your witnesses with a separate waiting area and the other measures listed. However, this is not always possible and can depend on the court facilities as to whether these measures are available.

Response to allegations of harm (page 8)

This section should only be illed in if the other party has served a completed form C1A.

If no form C1A is served with the application for an order the respondent will need to complete the form C1A to be returned with form C7 Response to an application under the Children Act 1989.

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