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F.C.A. 430, 550, 655, 828, 1029 General Form 5 09/06 ORI No: Integrated Dome stic Violence Part of the Supreme Court Order No: _______________ County of , State of New York NYSID No: (address) PRESENT: Hon. TEMPORARY ORDER OF PROTECTION [Articles 4, 5, 6, 8 and 10] In the Matter of a Proceeding under Article of the Family Court Act Docket No. Petitioner Family Unit No. (check one) Date of Birth: ‘ Ex Parte ‘ Both Parties Present in Court Respondent Date of Birth: NOTICE: YOUR FAILURE TO OBEY THIS ORDER MAY SUBJECT YOU TO MANDATORY ARREST AND CRIMINAL PROSECUTION, WHICH MAY RESULT IN YOUR INCARCERATION FOR UP TO SEVEN YEARS FORCRIMINAL CONTEMPT, AND/OR MAY SUBJECT YOU TO FAMILY COURT PROSECUTION AND INCARCERATION FOR UP TO SIX MONTHS FOR CONTEMPT OF COURT. IF YOU FAIL TO APPEAR IN COURT WHEN YOU ARE REQUIRED TO SO, THIS ORDER MAY BE EXTENDED IN YOUR ABSENCE AND CONTINUE INEFFECT UNTIL YOU APPEAR IN COURT. A petition under Article _ of the Family Court Act , sworn to on , having been filed in this Court in the above entitled proceeding, and good cause having been shown, the Respondent having been [check applicable box]: “ present in Court and advised of the issuance and contents of this Order “ not present in Court, Now, therefore, it is hereby ordered that [specify first name, middle initial and last name] observe the following conditions of behavior: [Check Applicable Paragraphs and Subparagraphs] : [01] “ Stay away from [A] “ [name(s) of protected persons]: and/or from the [B] “ home of , [C] “ school of ; [D] “ business of ,[E] “ place of employment of , [F] “ other [specify location] [14] “ Refrain from communication or any other contact by mail, telephone, e- mail, voice-mail or other means with [specify protected persons(s)]: ; [02] “ Refrain from assault, stalking, harassment, aggravated ha rassment, menacing, reckless endangerment, disorderly conduct, intimidation, threats or any criminal offense against [specify protected person(s) and/or members of protected person’s family or household, and/or person(s) with custody of child(ren)]: ; [15] ‘ Refrain from intentionally injuring or killing without justification the following companion animal ; [11] ‘ Permit [specify individual]: to enter the residence at [specify]: _during [specify date/time]: with [specify law enforcement ag ency, if any]: to remove personal belongings not in issue in litigation [ specify items]: ; [04] ‘ Refrain from [indicate acts]: that create an unreasonabl e risk to the health, safety or welfare of [specify child(ren), family or household membe r(s)]: ; [05] ‘ Permit [specify individual]: entitled by a court order or separation or other written agreement, to visit with [specify ch ild(ren)]: during the following periods of time [specify]: under the following terms and conditions [specify]: ; [07] ‘ Temporary custody of [specify child(ren)] shall be awarded to [specify individual] under the following terms and conditions [specify]: ; [12] ‘ Surrender any and all handguns, pistols, revol vers, rifles, shotguns and other firearms owned or possessed, including, but no t limited to, the following: and do not obtain any further guns or other firearms. Such su rrender shall take place immediately but in no event later than [specify date/time]: at [specify location]: . ‘ Pay or provide access to health or medical insurance for nece ssary medical care and treatment arising from the incident or incidents forming the basis of the order [specify benefi ciary of treatment and coverage] ; Arts. 5, 6&8 only ‘ Pay counsel fees and/or any costs associated with the order to [specify person and terms] ; Arts. 4,5&6 only ‘ Participate in an educational program (and pay the co sts thereof)[(specify program] ; GF-5 Page 2 Art. 8 only ‘ Participate in a batterer's education program desi gned to help end violent behavior (and pay the costs thereof)[specify program] ; and Art. 8 only ‘ Pay to the petitioner/victim(s) restitution, as follows [specify terms] (amount up to $10,000); [99] ‘Observe such other condition(s) as are necessary to further the purposes of protection [specify conditions]: It is further ordered that the above-named Respondent's license to carry, possess, repair, sell or otherwise dispose of a firearm or firearms, if any, pursuant to Penal Law '400.00, is hereby [13A] “ suspended, or [13B] “revoked, (note: final order only) and/or [13C] “ the Respondent shall remain ineligible to receive a fi rearm license during the period of this order. (Check all applicable boxes) It is further ordered that this temporary order of protection shall remain in effect until [s pecify date]: . The Family Court Act provides that presentation of a copy of this orde r of protection to any police officer or peace officer acting pursuant to his or her special duties shall authorize, and sometimes requires, such officer to arrest a person who is alleged to have violated its terms and to bring him or her before the Court to face penalties authorized by law. Federal law requires that this order must be honored and enforced by stat e and tribal courts, including courts of a state, the District of Columbia, a commonwealth, territory or possession of the United States, if the person against whom the order is so ught is an intimate partner of the protected party and has or will be afforded reasonable notice and opportunity to be heard in acco rdance with state law sufficient to protect that person's rights (18 U.S.C. §§ 2265, 2266). It is a federal offense to : cross state lines to violate an order of prot ection; cross state lines to engage in stalking, harassment or domestic violence against an intimate partner or fam ily member; possess, purchase, ship, transfer or receive a handgun, rifle, shotgun or other firearm or ammunition follo wing a conviction of a domestic violence misdemeanor involving th e use or attempted use of physical force or a deadly weapon; or (except for military or law enforcement officers while on duty) possess, purchase, ship, transfer or receive a handgun, rifle, shotgun or other firearm or ammunition while an order of protec tion, issued after notice and an opportunity to be heard, that protects an intimate partner against assault, harassment, threatening and/or stalking, remains in effect (18 U.S.C. ''922(g)(8), 922(g)(9), 2261, 2261A, 2262). Dated: JUSTICE COURT (COURT SEAL) PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO A PPELLANT BY THE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE LAW GUARDIAN UPON THE APPELLANT, WHICHEVER IS EARLIEST. Check Applicable Box(es): ‘ Party against whom order was issued was advi sed in Court of issuance and contents of Order ‘ Order personally served in Court upon party against whom order was issued ‘ Service directed by other means [specify]: ‘ [M odifications or extensions only]: Order mailed on [specify date and to whom mailed]: ‘ Warrant issued for party against whom order was issued [specify date]: