Fill and Sign the Check Only Boxes that Apply and Fill in Blanks Form

There is is not another court proc eeding betw een the defendant and me pending in this or any other state. (List county, state, date, and what kind of proceeding, if applicable.) The defendant has attempted to cause or has intenti onally caused me bodily injury; or has placed me or a member of my family or househ old in fear of immi nent serious bodily injury or in fear of continued harassment that rises to such a level as to inflict substantial emoti onal distress; or has committed a sexual offense against me in that: (Give specific dates and describe in detail what happened.) The defendant has attempted to cause or has intenti onally caused bodily injury to the child(ren) living with me or in my custody; has placed my child(ren) in fear of immi nent serious bodily injury or in fear of continued harassment that rises to such a level as to inflict substantial emoti onal distress; or has committed a sexual offense against the child(ren) in that: (Give specific dates and describe in detail what happened.) I live in C ounty, North Carolina. The defendant and I STATE OF NORTH CAROLINA File No. 6. 7. 5.4. I believe there is danger of serious and immediate injury to me or my child(ren). (Check this block if you ask for temporary child custody.) The defendant and I are the parents of the following child(ren) under the age of eight een. A COPY OF "AFFIDAVIT AS TO STATUS OF MINOR CHILD" (AOC-CV- 609) MUST BE ATTACHED FOR EACH CHILD. Name Sex Date O f Birth Name Sex Date O f Birth (Over) AOC-CV-303, Rev. 5/12, Page 1 of 3 © 2012 Administrative Office of the Courts 2. 1. (Check only boxes that apply and fill in blanks. Additional sheets may be attached.) County VERSUS COMPLAINT AND MOTION FOR DOMESTIC V IOLENCE PROTECTIVE ORDER G.S. 50B-1, -2, -3, -4 In The G eneral Court Of Justice District Court Division are persons of the opposite sex who are not married but live t ogether or have lived t ogether. are spouses. are former spouses. have a child in common. are parent and child or grandparent and gr andchild. are current or former househ old members. are persons of the opposite sex who are in or have been in a dating relationship. 3. Name And Address Of Defendant (Person Accused Of Abuse) Name Of Plaintiff (Person F iling Complaint) 6a. 3a . I w ant the care, cust ody, and c ontrol of any an imal owned, possess ed, kep t, or held as a pet by eit her pa rty or mi nor child residi ng in t he household gr anted to me. I w ant the de fend ant or dered no t to cruelly tr eat or abuse an an imal owned, possess ed, kep t, or held as a pet by eit her pa rty or mi no r child resi ding in the household. 4. 5. I w ant po ssessi on of our residence at t he address list ed be low, and I w ant the de fend ant to move from and not return to t he residence. I w ant the Cou rt to order t he evict ion of t he de fend ant from t he residence list ed above and I w ant assist ance in returni ng to t he residence. Address Of Residence 3. 2. 1. (Fill in the block if you are asking for temporary child custody) The mi nor child( ren) list ed in No 7. above is ex posed to a s ubstan tial risk of ph ysical or emotional injury or sex ual abuse in t hat:( Describe in detail what happened that created a risk of physical or emotional injury or sexual abuse.) 8. The de fend ant has fir earms and amm unition as described below, pe rmit to carry a c oncea led weap on. (Describe all firearms, a mmunition, gun permits and give identifying numbe r(s) if known, and indicate where defendant keeps firearms and gun permits.) 9. The de fend ant has us ed or thr eaten ed to use a deadly w eapon against me or mi nor child( ren) in my cust ody or has a pattern of prior c onduct involvi ng the use or thr eaten ed use of viol ence with a fir earm against any pe rson s in t hat(Give specific dates and describe in detail what happened.) 10. The de fend ant has made thr eats to commit suicide in t hat (Give specific dates and describe in detail what happened.) 11. AOC-CV-303, Rev. 5/12, Page 2 of 3 © 2012 Administrative Office of the Courts ha s a permit to purcha se a fir earm, and has a Becau se Of The Acts Of Domestic Violen ce By The Defendant, I Am Requ esting That The Court Gi ve Me The Following Relief: Since t here is a danger of acts of domestic viol ence against me or my child( ren), I w ant an Ex Parte Or der be fore notice of a heari ng is giv en to t he de fend ant. I w ant the Cou rt to order t he de fend ant not to assault, thr eaten , abuse, follow, harass or interfere with me and my child(r en). I w ant emergency relief. (Check only boxes that apply.) 6. I w ant po ssessi on of t he pe rsonal property such as clothi ng and household goods in t he residence list ed above ex cept for t he de fend ant's personal clothi ng, toiletries and t ools of trade. VERSUSF ile No. 7. (a)(c) (e) (g) (b) (d) (f) I w ant the de fendan t to be or dered no t to come on or ab out: my residence.t he place w here I work. t he place w here t he child(r en) receives day care. Ot he r: ( name ot her places) an y place w here I am receiv ing tem porary s helter. an y school(s) t he child(r en) attend. t he place w here I go to school. T he child(r en) curr ently attend: (name school) Notary Assistant CSC Deputy CSC Clerk of Superior Court Designated Magistrate 17 . 14 . 15 . 16 . 9. 8. 10 . 11 . 12 . 13 . AOC-CV-303, Rev. 5/12, Page 3 of 3 © 2012 Administrative Office of the Courts I w ant po ssessi on and use of t he followi ng veh icle: Describe Vehicle I w ant the de fendan t to be or dered to have no con tact with me. I w ant tem porary cust ody of our mi nor child(r en) list ed in this Complaint. I un derstand t hat I must file a separate child cust ody acti on for perm anen t cust ody. I w ant the de fendan t to be or dered to make paym ents for t he sup port of our mi nor child(r en), as requir ed by law, but I unde rstand it is only tem porary and t hat I mu st file a separate child sup port acti on for regular, perm anen t child su pport. I want the Cou rt to prohibit t he de fendan t from possessi ng or purcha sing a fir earm. I w ant the Cou rt to order t he de fendan t to surr ender to the she riff his/ her fir earms, amm unition , and gun permits to purcha se a fir ea rm and carry a c oncea led weapon . I w ant the de fendan t to be or dered to attend an abuser tr eatm ent pr ogram. I w ant the de fendan t to be or dered to provi de me and t he child(r en) suit able alter native housi ng. I, t he unde rsigned , be ing first duly sworn, say t hat I am t he plaintiff in this acti on; tha t I have read t he Complaint and Moti on; tha t the matters and thi ngs alle ged in the Complaint and Moti on are tr ue exc ept as to t hose thi ngs all eged upon informati on and belief and as to t ho se I believe t hem to be true and accurate. VERIFI CATIO N I w ant the de fendan t to be or dered to make paym ents for my sup port as requir ed by law, but I u nderstand it is only t empo rary and t hat I mu st file a separate acti on for regular perm anen t spousal s upport. Othe r:(specify) Signature Of Plaintiff (Person Filing Complaint) Date SEAL SWO RN/AFFIRMED AND S UBSCR IBED T O BEFORE ME Signature Signature Of Plaintiff (Person Filing Complaint) Date Date Name Of Plaintiff (Type Or Print) Date My Co mmission Expires County Where Notarized Name Of Defendant