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Approved: August 2001 Petition for Order of Protection: A.R.S. §13-3602 (A) Page 1 of 4 COURTS OF ARIZONA - NAME OF COURT Street Address City, Arizona Zip Code Phone Number Plaintiff Date of Birth Defendant Address City, State, Zip Code, TelephonePETITION FOR ORDER OF PROTECTION G MODIFIED Case Number NOTE: NO FILING FEES, But Service Fees May Be Waived or Deferred If You Are Unable to Pay DO NOT FILL OUT ADDRESSES AND/OR PHONE NUMBERS BELOW IF YOU WANT THEM KEPT PRIVATE 1. Is an action for maternity, paternity, annulment, legal separation or dissolution of marriage (divorce) now pending? G No G Yes: Case Number (if known): Where: 2. My (Plaintiff’s or child(ren)’s) relationship to the Defendant is (check all that apply): G Married: Date of marriage: G Divorced: Date divorce granted: G Living together now or in the past Note: (Statute change) G One of us is pregnant by the other or we have a child in common G Defendant is related to me: How? Approved: August 2001 Petition for Order of Protection: A.R.S. §13-3602 (A) Page 2 of 4 3. Have either of you been charged or arrested for domestic violence OR requested an Order of Protection or Injunction Against Harassment against the other? G No G Yes: If known: date, name of court, facts of case: 4. For the Court to issue an Order, the Defendant must have committed, or may commit, an act of domestic violence or some other good reason must exist. (Previous acts of domestic violence must have occurred within the past year unless the Defendant was in jail or prison or out of state.) Describe what the Defendant did or might do, including whether you fear bodily injury or death. Be as specific as possible, giving the date or approximate date for each action. Date(s) Describe what happened DESCRIPTION OF DEFENDANT SEX RACE DATE OF BIRTH HEIGHT WEIGHT EYES HAIR SOC. SEC. NO. ALIAS (if known): Defendant is: G Military G Law Enforcement 5. I ask this Court to order the Defendant not to commit an act of “domestic violence” against me and/or persons named below and/or against my property AND make the following Order(s) (check which Orders you want): G Waive or defer any Service fees. G Order the Defendant not to possess and/or purchase firearms and/or ammunition. G Order the Defendant to surrender firearms and/or ammunition. G Order the Defendant to participate in domestic violence counseling or other counseling. Approved: August 2001 Petition for Order of Protection: A.R.S. §13-3602 (A) Page 3 of 4 G Order the Defendant not to contact me: G in person; G by phone; G in writing; G . DO NOT FILL OUT ADDRESSES BELOW IF YOU WANT THEM KEPT PRIVATE The following persons should be included within the protection of this Order for the following reasons: Name and Address if different than yours (do not include yourself)Relationship to youD.O.B. Reason(s) Name: Address: Name: Address: Name: Address: G Keep my address private. (Do not check this box if the Defendant knows where you live.) G Order the Defendant not to come on or near (LEAVE YOUR RESIDENCE ADDRESS BLANK IF BOX ABOVE IS CHECKED): G My residence at: G My place of employment (Name and Address): Does the Defendant also work there? G Yes G No G School (Name and Address): G Other address: G Order that I be given the exclusive use of our residence (write address only if different from above): G Other requests: Approved: August 2001 Petition for Order of Protection: A.R.S. §13-3602 (A) Page 4 of 4 My Signature Date Attorney’s Signature Date V E R I F I C A T I O N I swear or affirm that the contents of this Petition are true to the best of my knowledge. Plaintiff or Third Party SUBSCRIBED AND SWORN to before me on Judicial Officer/Clerk/Notary Date