DV-100 Request for Domestic Violence Restraining Order

DV-100 Request for Order (Domestic Violence Prevention)

Clerk stamps date here when form is filed.

1 Your name (person asking for protection):

Your address (skip this if you have a lawyer):

City: State: Zip:

Your telephone number (optional):

Your lawyer (if you have one):

2 Name of person you want protection from:

Description of that person: Sex: M F Height: Weight: Race:

Hair Color: Eye Color: Age: Date of Birth:

3 Besides you, who needs protection? (Family or household members):

Full Name Age Lives with you? Yes No How are they related to you?

Full Name Age Lives with you? Yes No How are they related to you?

Full Name Age Lives with you? Yes No How are they related to you?

Full Name Age Lives with you? Yes No How are they related to you?

4 What is your relationship to the person in 2? (Check all that apply):

a. We are now married or registered domestic partners.

b. We used to be married or registered domestic partners.

c. We live together.

d. We used to live together.

e. We are relatives, in-laws, or related by adoption. Specify:

f. We are dating or used to date.

g. We are engaged to be married or were engaged to be married.

h. We are the parents together of a child or children under 18.

Child's Name: Date of Birth:

Child's Name: Date of Birth:

Child's Name: Date of Birth:

i. We have signed a Voluntary Declaration of Paternity for our child or children.

5 Other Court Cases

a. Have you and the person in 2 been involved in another court case? No Yes

If yes, where? County: State:

What are the case numbers?

What kind of case? (Check all that apply):

Registered Domestic Partnership Divorce/Dissolution Parentage/Paternity Legal Separation

Domestic Violence Criminal Juvenile Child Support Nullity Civil Harassment

Other Specify:

b. Are there any domestic violence restraining/protective orders now (criminal, juvenile, family)? No Yes

6 Personal Conduct Orders

I ask the court to order the person in 2 not to do the following things to me or any of the people listed in 3.

Harass, attack, strike, threaten, assault, hit, follow, stalk, molest, destroy personal property, disturb the peace, keep under surveillance, or block movements

Contact, telephone, send messages or mail or e-mail

7 Stay-Away Order

I ask the court to order the person in 2 to stay at least yards away from:

Me The people listed in 3 My home My job or workplace

The children's school or child care My vehicle Other Specify:

If the person listed in 2 is ordered to stay away from all the places listed above, will he or she still be able to get to his or her home, school, job, or place of worship? Yes No If no, explain:

8 Move-Out Order

I ask the court to order the person in 2 to move out from and not return to

I have the right to live at the above address because:

9 Child Custody, Visitation, and Child Support

I ask the court to order child custody, visitation, and/or child support. You must fill out and attach Form DV-105.

10 Spousal Support

I ask the court to order spousal support. You must file Form FL-150 before your hearing.

11 Record Unlawful Communications

I ask for the right to record communications made to me by the person in 2 that violate the judge's orders.

12 Property Control

I ask the court to give only me temporary use, possession, and control of the property listed here:

13 Debt Payment

I ask the court to order the person in 2 to make these payments while the order is in effect:

Check here if you need more space. Attach Form MC-020 and write “DV-100, Item 13—Debt Payment” by your statement.

Pay to: For: Amount: $ Due date:

Pay to: For: Amount: $ Due date:

Pay to: For: Amount: $ Due date:

14 Property Restraint

I ask the judge to order that the person in 2 not borrow against, sell, hide, or get rid of or destroy any possessions or property.

15 Attorney Fees and Costs

I ask that the person in 2 pay some or all of my attorney fees and costs.

16 Payments for Costs and Services

I ask that the person in 2 pay the following:

Pay to: For: Amount: $

Pay to: For: Amount: $

Pay to: For: Amount: $

17 Batterer Intervention Program

I ask the court to order the person listed in 2 to go to a 52-week batterer intervention program and show proof of completion to the court.

18 No Fee to Serve (Notify) Restrained Person

If you want the sheriff or marshal to serve (notify) the restrained person about the orders for free, ask the court clerk what you need to do.

19 More Time for Notice

I need extra time to notify the person in 2 about these papers.

I want the papers served up to days before the date of the hearing.

If necessary, add additional facts:

20 Other Orders

What other orders are you asking for?

Check here if you need more space. Attach MC-020 and write “DV-100, Item 20—Other Orders” by your statement.

21 Guns or other firearms.

I believe the person in 2 owns or possesses guns or firearms. Yes No I don't know

22 Describe the most recent abuse.

a. Date of most recent abuse:

b. Who was there?

c. What did the person in 2 do or say that made you afraid?

d. Describe any use or threatened use of guns or other weapons:

e. Describe any injuries:

f. Did the police come? No Yes

If yes, did they give you an Emergency Protective Order? Yes No I don't know

Check here if you need more space. Use Form MC-020 and write “DV-100, Item 22—Recent Abuse” by your statement.

Check here if the person in 2 has abused you (or your children) other times. Use Form DV-101 or Form MC-020 to describe any previous abuse.

I declare under penalty of perjury under the laws of the State of California that the information above is true and correct.