Description of Harm:

Petitioner is not a person eligible for relief

Petitioner Failed to AppearLack of Service- Exceeded the statutory time limit (6 months)Petitioner Requested Dismissal

No statutory basis for relief

D. The Respondent has access to firearm(s).

on at

A vulnerable adult.An individual who has a child(ren) in common with the Respondent. No. of Children: Ages:

JUDGES' WORKSHEETFINAL PROTECTIVE ORDER

After the appearance of the Petitioner Petitioner's Counsel Respondent Respondent's Counsel, and in consideration of thePetition and evidence, the Court makes the following.A. Person Eligible for Relief is:

The current spouse of the Respondent.A former spouse of the Respondent.A cohabitant with the Respondent.An individual related to the Respondent by blood, marriage, or adoption

B. Petitioner is:

Relationship

The person eligible for relief.In the case of a vulnerable adult or minor child:

Date

A State's AttorneyA relative

A local department of social servicesAn adult residing in the home

C. Consent/Abuses:

Caused serious bodily harmPlaced person(s) eligible for relief in fear ofimminent serious bodily harm

False ImprisonmentStalking

The Respondent consents to the entry of a Final Protective Order without admitting the allegations in the Petitionor a judicial finding of abuse.

There is a preponderance of the evidence to believe that the Respondent committed the following act(s) of abuse:OR

Assault in any degreeRape or statutory sexual offense (or attempt)in any degree

Statutory abuse of a child ( Physical Sexual Mental)Statutory abuse of a vulnerable adult

Time

FINDINGS:

Eligible for two (2) year Final Protective Order:A Final Protective Order was issued against the Respondent on behalf of this Petitioner.The act of abuse was committed within one (1) year after the date that a prior Final Protective Order issued againstthe same Respondent on behalf of the same person eligible for relief expires.

The prior Final Protective Order was issued for a period of at least six (6) months.

..

.Eligible for extended protection for up to two (2) years from the date granted.

A Final Protective Order was issued against the Respondent on behalf of this Petitioner...The Petitioner or a protected person was a victim of a subsequent act of abuse during the active period of the orderof protection.

Case No.:Petitioner:Address:

PLACE LABEL HERE. IF AVAILABLE

Parties advised that testimony will be recorded.Parties advised of 5th Amendment rights.

Criminal charges pending.Court reviewed civil case history.

E. Vacate Requested - Respondent and person(s) eligible for relief resided together at the time of the abuse and:Are married, orAre not married, but the name of the person eligible for relief appears on the lease or deed to the home, orAre not married, but the person eligible for relief has shared the home with the Respondent for a period of atleast 90 days within one (1) year before the filing of the Petition.

G. Petition Denied

H. Petition Dismissed

Petitioner could not meet required burden of proof

Lack of Personal JurisdictionImproper VenueOther

Other

A parent, stepparent, child, or stepchild of the Respondent or person(s) eligible for relief who resides or resided withthe Respondent or person(s) eligible for relief for at least 90 days within one (1) year before the filing of the Petition.

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F. Hearing Waived - The parties have agreed to waive the Temporary Protective Order hearing.

The Respondent named in the protective order consents to the extension of the protective order..

By consent of the Respondent, within one (1) year after the date that a prior Final Protective Orderissued against the same Respondent, on behalf of the same person eligible for relief expires.

.An individual who has had a sexual relationship with the Respondent within one (1) year before the filing of the Petition.

An undisclosed temporary residence of for reasons of safety.

An undisclosed home of another family member, . Location is withheld for reasons of safety.

An undisclosed school of for reasons of safety.

An undisclosed childcare provider for reasons of safety while is in the care of the childcare provider.

Enter an undisclosed location for reasons of safety.

(1) Place of employment: at

(1) Childcare provider: at while is in the care of the childcare provider.

(1) School:

4. Enter the residence of at

(1) Temporary residence of:

at

(2) Childcare provider: at while is in the care of the childcare provider.

(Residence includes yard, grounds, outbuildings, and common areas surrounding the dwelling.)

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(2) Temporary residence of:

at

(3) School:

(2) School:

Case No.

5. Respondent SHALL STAY AWAY from:

(2) Place of employment: at

An undisclosed place of employment of for reasons of safety.

3. Contact, attempt to contact, or harass (in person, by telephone, in writing, or by any other means)

except to facilitate any child visitation ordered below.

Respondent SHALL NOT:

2. Abuse or threaten to abuse

Court ORDERS:

1. This Order is effective through at 11:59 P.M.

The home of another family member, at

Date

CC-DC-DV-003W (Rev. 10/2016)

8. Visitation with

is granted to

The following additional visitation terms apply (e.g., transportation, exchange location, name of visitation coordinator, etc.):

It is to occur every other weekend from to ; every

from until ;

as directed by local law enforcement.

Visitation shall be supervised by

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Custody shall remain as set forth in

The child(ren) shall primarily reside with

Law enforcement officers are ordered to use all reasonable and necessary force to return the minor child(ren) to the custodial parent after service of this Order.

7. Custody of is awarded to Custody of is awarded to

Custody shall remain joint.

Case Number

The Respondent, accompanied by a law enforcement officer, may return to collect clothing and personal necessities, only between the hours of and on or

Time Time Date

and remain away. Temporary use and possession of the home is granted to

Case No.

Name(s) of Child(ren)

Name(s)

Day

Time of Day Time of Day

6. Respondent SHALL VACATE the home immediately (home includes yard, grounds, outbuildings, and common areas surrounding the dwelling) at:

9. Respondent SHALL PAY Emergency Family Maintenance in the amount of $ every week 2 weeks month to beginning and mail payment to the following address:

Emergency Family Maintenance shall be paid by way of an Earnings Withholding Order.

Name

Date

CC-DC-DV-003W (Rev. 10/2016)

11. Respondent SHALL participate in and meet the requirements of the following domestic violence and/or other

professionally supervised counseling program(s):

1. 2.

Each party shall be served with a copy of this Final Protective Order. The clerk shall mail additional copies to thefollowing:

3. 4.

Judge ID NumberDate

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Case No.

10. Exclusive use and possession of the vehicle described as:

is granted to

X

16. This Order supersedes and overrides any previously entered Final Protective Order.

13. Temporary possession of the pet(s)

Name

Name and Description

is awarded to

Name(s)

firearm, for the duration of this Final Protective Order.

15. The following additional relief is necessary to protect the person eligible for relief from abuse:

14. Respondent SHALL pay costs, including costs for out-of-state service.

17. Additional Conditions:

Petitioners SHALL participate in and meet the requirements of the following domestic violence and/or other

professionally supervised counseling program(s):

SHALL participate in and meet the requirements of the following

domestic violence and/or other professionally supervised counseling program(s):

12. Respondent SHALL immediately surrender all firearm(s) to law enforcement agency

, and refrain from possession of any

CC-DC-DV-003W (Rev. 10/2016)