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FCA §§154-d, 822; CPL §§530.12 (3),(3-a),(3-b) Family Court General Form 5c Criminal Form 4 (Local Criminal Court): 12/2013 County of _________________________________ Petitioner on behalf of [specify]: AFFIDAVIT IN SUPPORT OF ISSUANCE OF FAMILY COURT TEMPORARY ORDER OF -against-- PROTECTION (By Peace or Police Officer, Agency or Designated Person) Respondent Index/Docket # _______________________________________ State of New York ) ): ss: County of ) I, (petitioner's name) ____________________________ _______, having been duly sworn, depose and state the following upon information and belief under the penalties of perjury: 1. a. I am a [check applicable box]: ” peace or police officer ” representative of the following duly authorized a gency, association, society or institution [specify]: ” person designated by the Court to file a family of fense petition pursuant to FCA §822(d). b. I am submitting this affida vit in support of the issuance of a temporary order of protection to protect [specify names of protected persons]: 2. The Family Court, County, is not i n session at the present time. 3. The following family offense(s) was/were commit ted on (specify date): ________ by the above- named Respondent [Check box or boxes]: ” Disorderly conduct ” Menacing in the 2 nd or 3 rd degree ” Harassment in the 1 st or 2 nd degree ” Reckless endangerment ” Assault in the 2 nd or 3 rd degree ” Aggravated harassment in the 2 nd degree ” Attempted assault in 2 nd or 3 rd degree ” Stalking ” Criminal mischief ” Sexual misconduct ” Forcible touching ” Sexual abuse in the 2 nd 1 or 3 rd degree ” Strangulation ” Criminal obstruction of breathing or circulation ” Identity theft in 1 st, 2 nd or 3 rd degree ” Grand larceny in 3 rd or 4 th degree ” Coercion in 2 nd degree [Penal Law §135.60 (1),(2),or (3) 1 Where victim is incapable of consent for reason oth er than being under age 17 [Penal Law §130.60(1)]. Family Court General Form 5c\Crim 4 Page 2 4. a. The above family offense(s) were committed against [specify]: b. The relationship of Respon dent to the victim of the above family offense is [ check box]: ” They are married ” They were married ” They have a child in common ” They are parent and child ” They are related by blood or marriage [specify h ow]: ” They have an intimate relationship (NOT casual s ocial or business acquaintances) [describe]: ” They had an intimate relationship (NOT casual so cial or business acquaintances)[describe]: 5. [Check box]: ” I filed a petition under Article 8 of the Family Court Act in Family Court,_____________County, on [specify date]:__________. ” I intend to file a petition in Family Court, _____ _______County, on the next day the Court is in sess ion. ” The above-named victim filed a petition under Arti cle 8 of the Family Court Act in Family Court,______________County, on [specify date]:____ ______. ” The above-named victim informed me that (s)he int ends to file a petition in Family Court, County, on the next day the Court is in session. 6. The following constitutes good cause for issuing a temporary order of protection:[Brie fly describe family offense and any other facts and rea sons supporting the need for protection of the abov e- named victim(s) and members of his/her/their househ olds or families]: 7. a. The following criminal, matrimonial or Famil y Court cases have been filed involving the respondent and the proposed protected party or part ies: [Specify type of case, who filed it, the court in which it was filed, the approximate date filed and the present status, if known]: b. The following orders of protection or tempo rary orders of protection have been issued against the respondent or against the proposed prot ected party or parties: [Specify type of case in which the order was issued, persons protected by the order, t he court that. issued it, the approximate date issued and expiration date, if known]: 8. I understand and have informed the proposed pro tected party or parties that the Family Court order issued by this Court will expire on the date indicated on the order, which will be not more than four calendar days after its issuance, unless sooner vac ated or modified by the Family Court. I understand and have informed the proposed protected party or parti es that the matter will be transferred to the Family Court and that they must appear in Family Court on or before the date indicated and that, if I am or will be the Petitioner in Family Court, I must appear as we ll. I further understand and have informed the proposed protected party or parties that they and/o r I have a right to seek a criminal prosecution of respondent in addition to, or instead of, proceedin g in Family Court. WHEREFORE, for the reasons stated above, I am reque sting that my application for a Family Family Court General Form 5c\Crim 4 Page 3 Court temporary order of protection be granted and that the matter be transferred to the Family Court, ________________ County. False statements in this affidavit are punishable a s a class A misdemeanor, pursuant to Penal Law §210.45. Sworn to before me this day of ________________________ Petitioner __________________________ (JUDGE): (SUPERIOR OR DESK OFFICER, POLICE DEPARTMENT): (NOTARY PUBLIC): TO THE CLERK OF COURT: This affidavit, together with any temporary order of protection so issued, shall be transmitted forthwith to the Family Court; if the affidavit and order are transmitted by facsimile or other electronic means , the original shall be forwarded immediately thereafter.