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1 SC-26 THE SUPERIOR COURT FOR THE COUNTY OF STATE OF GEORGIA : Petitioner, : Civil Action File : v. : : No. : Respondent. : PETITION FOR TEMPORARY PROTECTIVE ORDER The Petitioner, pursuant to the Family Violence Act O.C.G.A. § 19-13-1 et seq., files this Petition for a Family Violence Protective Order and in support shows the Court the following: 1. Petitioner is a resident of County, Georgia, and is 18 years of age or older or is an emancipated minor. Petitioner's year of birth is , sex and race 2. Respondent is a resident of County, Georgia, and may be served at Georgia. Jurisdiction and venue are proper with this Court. OR 2.1 Respondent is a resident of the State of Under O.C.G.A. § 19-13-2 jurisdiction and venue are proper with this Court because the abuse occurred in the State of Georgia in County and/or Petitioner lives in County. Respondent is subject to the jurisdiction of this Court and may be served at 3. Petitioner and Respondent are: 1. Present or past spouses 2. Parents of the same child/ren 3. Parent and child/ren 4. Persons who used to live in the same household 5. Persons currently living in the same household 6. Foster parent and foster child 7. Stepparent and stepchild 4. On or about Respondent committed the following acts of family violence against Petitioner and/or the minor child/ren: For your convenience, this form has been designed to be completed online. The information typed on the first page will automatically update to the other pages. Please be sure all pertinent information is completed before printing. Once the form is completed, select 'Print' to print the form. Selecting 'Reset' will clear the entire form. Print Reset ---PAGE BREAK--- 2 Petitioner is in reasonable fear for Petitioner's own safety and/or the safety of the minor child/ren. 5. At other times Respondent has committed other such acts, including but not limited to (approximate dates and what happened): 6. There is a substantial likelihood that Respondent will commit such acts of violence against Petitioner and the minor child/ren in the immediate future if relief is not granted as provided pursuant to O.C.G.A. § 19-13-4. Check the paragraphs below that apply to your case. Fill in the information needed by each paragraph you check. 7. Petitioner and Respondent have child/ren under the age of 18. Their names, years of birth, sex, and ages are These child/ren have lived only with Petitioner and Respondent for the past five years. (If the child/ren have not resided only with Petitioner and Respondent for the last five years, give the names of the persons, their addresses, and the dates the child/ren resided with them ---PAGE BREAK--- 3 8. The parties are not married and Respondent (has OR has not) legitimated the child/ren of the parties. 9. Petitioner (does OR does not) have knowledge concerning custody or claims of custody concerning these child/ren including divorce, separation, juvenile, and DFCS cases. Specify court and type of case (if applicable) 10. Petitioner has the following minor child/ren living with Petitioner whom Petitioner wishes protected from Respondent and including in the Protective Order (names and ages): 11. Petitioner believes Respondent has a criminal record and has committed the following crimes (approximate dates and crimes): 12. Petitioner fears that if Respondent learns of Petitioner's current address that Respondent will hurt or injure Petitioner or Petitioner's immediate family. Petitioner requests that Respondent not be informed of Petitioner's current residence. 13. Petitioner is dependent upon the family residence for shelter for Petitioner and/or minor child/ren and asks that Petitioner be granted the temporary use and possession of said residence, located at together with all personal property contained therein with the exception of Respondent’s personal clothing. 14. Petitioner and the minor child/ren are dependent upon the Respondent for support and requests that Petitioner be awarded temporary child support. 15. Petitioner is dependent upon Respondent for support and asks that Petitioner be awarded temporary support. 16. The minor child/ren are currently in the custody and control of Petitioner/Respondent and Petitioner asks for legal and physical custody. 17. Petitioner asks that the following assets/property of Petitioner be returned by Respondent: ---PAGE BREAK--- 4 THEREFORE, Petitioner asks: That the Court set a hearing no later than thirty (30) days from the filing of the Petition and direct Respondent to appear before this Court and show any reasons why the demands of the Petitioner should not be granted; That the Respondent be served a copy of this Petition and Ex Parte Protective Order as required by law; That this Court direct law enforcement to enforce this Order; That this Court direct Respondent to stop abusing, harassing and intimidating Petitioner and/or Petitioner’s child/ren; That this Court restrain and enjoin Respondent from having any direct or indirect contact with the Petitioner and/or Petitioner’s child/ren; That this Court order that Respondent be enjoined from approaching within yards of Petitioner; That this Court make findings of fact and conclusions of law concerning the issues in this case; That Petitioner have such other and further relief as the Court may deem just and proper; That this Court issue Family Violence Ex Parte and Twelve Month Protective Orders to: Check the paragraphs below that apply to your case. Fill in the information needed by each paragraph you check. award Petitioner temporary sole legal and physical custody of the minor child/ren; order Respondent to vacate the family residence at instanter; grant Petitioner exclusive temporary use and possession of the family residence at and all personal property of the parties located at the family ---PAGE BREAK--- 5 residence and Petitioner’s current residence with the exception of Respondent’s personal clothing; that law enforcement (sheriff or police department) assist Petitioner in returning to the family residence and in ensuring that the Respondent vacates said residence and that all keys, garage door openers and other security devices to the family residence are secured and given to the Petitioner; order Respondent to provide suitable alternate housing for Petitioner and/or Petitioner’s children; order Respondent to stay away from Petitioner’s and/or Petitioner’s minor child/ren’s place of residence, place of employment, and/or school; order Respondent’s visitation with the minor child/ren be limited to no visitation or ; order Respondent to pay to Petitioner child support for the minor child/ren; order Respondent to pay spousal support for Petitioner; award Petitioner costs and attorney’s fees for having to bring this action; order that Petitioner’s current address be kept confidential; enjoin and restrain Respondent from selling, disposing or encumbering, trading, contracting to sell, or otherwise disposing or removing from the jurisdiction of this Court any of the property of Petitioner or of the parties except in the ordinary course of business; enjoin and restrain Respondent from disconnecting the home utilities, changing and/or canceling auto, health or life insurance for Respondent, Petitioner, and/or the Petitioner’s minor child/ren, and/or interfering with Petitioner’s or the Petitioner’s minor child/ren’s mail; grant Petitioner the use of the following automobile: Make , Model Year and law enforcement (sheriff or police department) ensure that all keys to said vehicle be immediately returned to Petitioner; permit Petitioner to remove the following property from the residence for the exclusive use by Petitioner and/or the minor child/ren and law enforcement (sheriff or police department) be ordered to assist Petitioner during this removal; ---PAGE BREAK--- 6 order Respondent to undergo evaluation for drug/alcohol abuse and to follow the recommended treatment; order Respondent to undergo a batterer’s intervention program and to follow the recommended treatment; order Respondent to return to Petitioner immediately; order Respondent to reimburse Petitioner for damages or expenses for the following: order additional relief as follows: Respectfully submitted, Petitioner Address Telephone: (Do not give current address if confidential; give alternative address) ---PAGE BREAK--- 7 THE SUPERIOR COURT FOR THE COUNTY OF STATE OF GEORGIA , : Petitioner, : Civil Action File : v. : No. : , : Respondent. : VERIFICATION Personally appeared who being duly sworn states that she/he is the Petitioner in the above styled case and that the facts set forth in the foregoing Petition for Temporary Protective Order are true and correct. Petitioner Sworn and subscribed before me this day of , NOTARY PUBLIC My commission expires: ---PAGE BREAK--- 8 CIVIL ACTION FILE NO. Pursuant to O.C.G.A. § 19-13-3, Petitioner assisted by Name: Address: Phone: ---PAGE BREAK--- 9 *REMOVE THIS PAGE FROM ORDER AND FILE SEPARATELY UNDER SEAL* RESPONDENT’S IDENTIFYING FACT SHEET (please complete as much as possible; one of these must be provided to have the order placed in the National Crime Information Center registry: Respondent’s date of birth OR social security number) Respondent’s social security number is date of birth is sex color of hair color of eyes height weight Respondent’s race is ethnic background Respondent has distinguishing marks (tattoos, scars, Respondent drives a license tag and has a ___(state) driver’s license no: Respondent’s home address and is employed at and works from to on Respondent has the following known aliases: PROTECTED PARTIES’ IDENTIFYING INFORMATION Petitioner: DOB sex race Other: DOB sex race Other: DOB sex race Other: DOB sex race Other: DOB sex race Rev'd 8/14 CONFIDENTIAL INFORMATION FORM - ATTENTION COURT STAFF: THIS PAGE IS A RESTRICTED-ACCESS DOCUMENT. This document is not accessible to the public or to other parties.