Fill and Sign the A Member of My Family or Household is a Victim of Domestic Violence Committed by the Form

Petition for Order for Protec tion (PTORPRT) - Page 1 of 7 WPF DV -1.015 Mandatory (07/2019 ) - RCW 26.50.030 C ourt of W ashington For Petitioner vs. Respondent No. Petition for Order for Protection (PTORPRT) 1. [ ] I am a victim of domestic violence committed by the respondent. [ ] A member of my fami ly or household is a victim of domestic violence committed by the respondent. [ ] I am a [ ] guardian [ ] guardian ad litem [ ] next friend of a minor who is 13 to 15 years of age and is a victim of domestic violence in a dating relationship with a person age 16 or older. The name of the minor victim is _________ ______________________________ . This person’s identifying information is provided in paragraph 5 below. 2. [ ] The victim lives in this county. [ ] The victim left their residence becau se of abuse and this is the county of their new or former residence. 3. The victim’s age is: Respondent's age is: [ ] Under 16 [ ] 16 or 17 [ ] 18 or over [ ] Under 16 [ ] 16 or 17 [ ] 18 or over 4. The victim and the respondent are : [ ] Intimate Partners because they are : [ ] current or former spouses or domestic partners [ ] parents of a child -in-common [ ] age 16 or older and are/were in a dating relationship, and are currently residing together or resided together in the past [ ] age 16 or older and are/were in a dating relationship, but have never resided together. [ ] Family or household members because they are : [ ] current or former adult cohabitants as roommates [ ] adult in-laws [ ] adults related by blood [ ] parent and child [ ] stepparent and stepchild [ ] grand parent and grand child . Petition for Order for Protec tion (PTORPRT) - Page 2 of 7 WPF DV -1.015 Mandatory (07/2019 ) - RCW 26.50.030 5. Identification of Minors ( if applicable) [ ] No Minors involved. Name (First, Middle Initial, Last) Age Race Sex How Related to Petitioner Respondent Resides with 6. Other court cases or other restraining, protection or no -contact orders involving me, the minors and the respondent: Case Name Case Number Court/County I Request an Order for Protection following a hearing that will : 1 [ ] Restrain respondent from causing any physical harm, bodily injury, assault, including sexual assault, and from molesting, harassing, threatening, or stalking [ ] me [ ] the minors named in paragraph 5 above [ ] these mino rs only: (If the court orders this relief, and you and the respondent are current or former spouses or domestic partners, parents of a child -in-common, age 16 or older and are/were in a dating relationship, and are currently residing together or resided t ogether in the past, age 16 or older and are/were in a dating relationship, but have never resided together , the respondent will not be able to obtain or possess a firearm, other dangerous weapon, ammunition, or concealed pistol license for the duration o f the order.) 2 [ ] Restrain respondent from harassing, following, keeping under physical or electronic surveillance, cyberstalking as defined in RCW 9.61.260, and using telephonic, audiovisual, or other electronic means to monitor the actions, location s, or wire or electronic communication of [ ] me [ ] the minors named in paragraph 5 above [ ] only the minors listed below; [ ] members of the victim’s household listed below [ ] the victim’s adult children listed below: 3 [ ] Restrain respon dent from coming near and from having any contact whatsoever, in person or through others, by phone, mail, or any means, directly or indirectly, except for mailing of court documents, with [ ] me [ ] the minors named in paragraph 5 above, subject to an y court -ordered visitation [ ] these minors only, subject to any court -ordered visitation: 4 [ ] Exclude respondent from [ ] our shared residence [ ] my residence [ ] my workplace [ ] my school [ ] the residence, day care, or school of [ ] the minors named in paragraph 5 above [ ] these minors only: [ ] other: You have a right to keep your residential address confidential. Petition for Order for Protec tion (PTORPRT) - Page 3 of 7 WPF DV -1.015 Mandatory (07/2019 ) - RCW 26.50.030 5 [ ] Direct respondent to vacate our shared residence and restore it to me. 6 [ ] Prohibit respondent fr om knowingly coming within, or knowingly remaining within __________________ (distance) of [ ] our shared residence [ ] my residence [ ] my workplace [ ] my school [ ] the day care or school of [ ] the minors named in paragraph 5 above . [ ] these minors only: [ ] other: 7 [ ] Grant me possession of essential personal belongings, including the following: 8 [ ] Grant me use of the following vehicle: Year, Make & Model _____________________________ License No. 9[ ] Other : Protection involving a minor: 10 [ ] Subject to any court -ordered visitation, Grant me the care, custody and control of [ ] the minors named in paragraph 5 above [ ] these minors only: 11 [ ] Restrain respondent from interfering with my physical or legal c ustody of [ ] the minors named in paragraph 5 above [ ] these minors only: 12 [ ] Restrain the respondent from removing from the state: [ ] the minors named in paragraph 5 above [ ] these minors only: Additional Requests: 13 [ ] Direct the r espondent to participate in appropriate treatment or counseling services. 14 [ ] Require the respondent to pay the fees and costs of this action. 15 [ ] Remain Effective longer than one year because respondent is likely to resume acts of domestic vio lence against me if the order expires in a year. Protection involving pets. 16 [ ] Grant me exclusive custody and control of the following pet(s) owned, possessed, leased, kept, or held by me, respondent, or a minor child residing with either me or the respondent. (Specify name of pet and type of animal.): _____________ _______________________________________________. Petition for Order for Protec tion (PTORPRT) - Page 4 of 7 WPF DV -1.015 Mandatory (07/2019 ) - RCW 26.50.030 17 [ ] Prohibit respondent from interfering with my efforts to remove the pet(s) named above. 18 [ ] Prohibit respondent from kno wingly coming within, or knowingly remaining within _______________ (distance) of the following locations where the pet(s) are regularly found: [ ] petitioner's residence (You have a right to keep your residential address confidential.) [ ] _____ ______ _____________________________ ___ Park [ ] other:_____________ _________________________________________ Protection from Firearms and Other Dangerous Weapons 19 [ ] Require the respondent to surrender all firearm s, other dangerous weapon s, and any conce aled pistol license s, and prohibit the respondent from accessing, obtaining , or possessing firearm s, other dangerous weapon s, or concealed pistol license s. Notice: If you are the respondent’s intimate partner, after actual notice and an opportunity to be heard at the hearing, the court may be required to order the respondent to surrender firearms, other dangerous weapons, or concealed pistol license s. I want e mergency temporary protection effective immediately, that lasts (up to 14 days) until the court hearing : [ ] An emergency exists as described below . I request that a Temporary Order for Protection granting the relief requested above in 1) through 12 ) be issued immediately, without prior notice to the respondent, to be effective until the hearing. [ ] I also request temporary surrender all firearm s, other dangerous weapon s, and any concealed pistol license s without notice to the other party because irreparable injury could result if an order is not issued until the hearing. What irreparable harm wo uld result if an order is not issued immediately without prior notice to the respondent? __________________________________________________________________________ __________________________________________________________________________ ________________ __________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Request for Special Assistance from Law Enforc ement Agencies : I request the court order the appropriate law enforcement agency to assist me in obtaining: [ ] Possession of my residence. [ ] Possession of the vehicle designated above . [ ] Possession of my essential personal belongings at [ ] the shared residence [ ] respondent’s residence [ ] other location _______________________________________________________ . [ ] Custody of [ ] the minors named in paragraph 5 above [ ] these minors only ( if applicable): . Petition for Order for Protec tion (PTORPRT) - Page 5 of 7 WPF DV -1.015 Mandatory (07/2019 ) - RCW 26.50.030 [ ] Other : . “Domest ic violence ” means physical harm, bodily injury, assault, including sexual assault, stalking, Or inflicting fear of imminent physical harm, bodily injury or assault between family or household members. Statement: The respondent has committed acts of dom estic violence as follows. (Describe specific acts of domestic violence and their approximate dates , beginning with the most recent act . You may want to include police responses.) Describe the most recent violent act, fear or threat of violence , and why the temporary order should be entered today without notice to the respondent : . Describe the past incidents where you experienced violence, where you were afraid of injury or where the respondent threatened to harm or k ill you: Petition for Order for Protec tion (PTORPRT) - Page 6 of 7 WPF DV -1.015 Mandatory (07/2019 ) - RCW 26.50.030 . Describe any violence or threats towards children: . Describe any stalking behavior by respondent , including use of telephonic, audiovisual or electronic means to harass or monitor : . Describe medical treatment you received and for what: . Describe any threats of suicide or suicidal behavior by the respondent: . Does the respondent own or possess firearms? [ ] Yes [ ] No Does the respondent use firearms, we apons or objects to threaten or harm you? Please describe: . Has the respondent used, displayed, or threatened to use a firearm or other dangerous weapon in a felony? Please describe: . Is the respondent ineligible to possess a firearm under the provisions of RCW 9.41.040? Please describe: Petition for Order for Protec tion (PTORPRT) - Page 7 of 7 WPF DV -1.015 Mandatory (07/2019 ) - RCW 26.50.030 . Does possess ion of a firearm or other dangerous weapon by the respondent present a serious and imminent threat to public health or safety, or to the health or safety of any individual? Please describ e: . If you are requesting that the protection order lasts longer than one year, describe the reasons why: . Other: . (Continue on separate page if necessary .) Check box if substance abuse is involved: [ ] alcohol [ ] drugs [ ] other [ ] Personal service cannot be made upon respondent within the state of Washington. I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Dated: at , Washington. Signature of Petitioner You have a right to keep your residential address confidential. If you have one, please provide an address, other than your residence, where you may receive legal documents: .