THE SUPERIOR COURT FOR THE COUNTY OF_______________
STATE OF GEORGIA
_____________________, ]
Petitioner, ] Civil Action File
]
v. ] No. ____________
]
_____________________, ]
Respondent. ]
PETITION FOR TEMPORARY PROTECTIVE ORDER
The Petitioner, pursuant to the Family Violence Act at O.C.G.A. '' 19-13-1 et seq ., files
this Petition for a Family Violence Protective Order and in support shows the Court the
following:
1. The Petitioner is a resident of __________________ County, Georgia, and is 18
years of age or older or is an emancipated minor. Petitioner’s date of birth is
__________________, sex _____, race _______.
2. The Respondent is a resident of ___________________, County, Georgia and
may be served at
__________________________________________________________,
_____________ Georgia. Jurisdiction and venue are proper with this Court.
OR
2a. Respondent is a resident of the State of _________________. Under O.C.G.A. '
19-13-2(b) jurisdiction and venue are proper with this Court because the abuse
occurred in the State of Georgia in _________ County and/or the Petitioner lives
in ________________ County. Respondent is subject to the jurisdiction of this
Court and may be served at
_________________________________________________.
3. Petitioner and Respondent are:
____ 1. Present or past spouses
____ 2. Parents of the same child/ren
____ 3. Parent and child/ren
____ 4. Persons who used to live in the same household
____ 5. Persons currently living in the same household
____ 6. Foster parent and foster child
____ 7. Stepparent and stepchild
4. On or about , , the Respondent committed the following
acts of family violence against the Petitioner and/or minor child/ren
_________________
1
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Petitioner is in reasonable fear for Petitioner ’ s own safety and/or the safety of the
minor child/ren.
5. At other times the Respondent has committed other such acts, including but not
limited to (approximate dates and what happened)
____________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
6. There is a substantial likelihood that the Respondent will commit such acts of
violence against the Petitioner and minor child/ren in the immediate future if
relief is not granted as provided pursuant to O.C.G.A. ' 19-13-4.
Check the paragraphs below that apply to your case. Fill in the information needed by
each paragraph you check.
____ 7. Petitioner and Respondent have ______ child/ren under the age of 18.
Their names, birth dates, sex and ages
are_____________________________________________
__________________________________________________________________
_
__________________________________________________________________
These child/ren have lived only with Petitioner and Respondent for the past five
(5) years. (If the child/ren have not resided only with the Petitioner and
2
Respondent for the last five years give names of the persons, their addresses, and
dates the child/ren resided with
them)____________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
____ 8. The parties are not married and the Respondent ________ (has OR has
not)
legitimated the child/ren of the parties.
____ 9. Petitioner (does OR does not) have knowledge concerning custody or
claims of custody concerning these child/ren including divorce, separation,
juvenile and DFCS cases. Specify court and type of case(if applicable)
__________________________________________________________________
____ 10. Petitioner has the following minor child/ren living with Petitioner whom
the Petitioner wishes protected from the Respondent and included in the
Protective Order (names and
ages):_____________________________________________________
__________________________________________________________________
__________________________________________________________________
____ 11. Petitioner believes Respondent has a criminal record and has committed
the following crimes: (approximate dates and crimes)
__________________________
__________________________________________________________________
____ 12. Petitioner fears that if Respondent learns of Petitioner’s current address
that Respondent will hurt or injure Petitioner or Petitioner’s immediate family.
Petitioner requests that Respondent not be informed of Petitioner’s current
residence.
____ 13. Petitioner is dependent upon the family residence for shelter for the
Petitioner and/or minor child/ren and asks that Petitioner be granted the
temporary use and
possession of said residence, located at______________________________
together with all personal property contained therein with the exception of
Respondent’s personal clothing.
____ 14. Petitioner and minor child/ren are dependent upon the Respondent for
support and requests that Petitioner be awarded temporary child support.
____ 15. Petitioner is dependent upon the Respondent for support and asks that
Petitioner be awarded temporary support.
3
____ 16. The minor child/ren are currently in the custody and control of the
Petitioner/Respondent and Petitioner asks legal and physical custody.
____ 17. Petitioner asks that the following assets/property of the Petitioner be
returned by the Respondent :
_________________________________________________________
THEREFORE, Petitioner asks:
(a) That the Court set a hearing no later than thirty (30) days from the filing of the
Petition and direct Respondent to appear before this Court and show any reasons
why the demands of the Petitioner should not be granted;
(b) That the Respondent be served a copy of this Petition and Ex Parte Protective
Order as required by law;
(c) That this Court direct law enforcement to enforce this Order;
(d) That this Court direct Respondent to stop abusing, harassing and intimidating
Petitioner and/or Petitioner’s child/ren;
(e) That this Court restrain and enjoin Respondent from having any direct or indirect
contact with the Petitioner and/or Petitioner’s child/ren;
(f) That this Court order that Respondent be enjoined from approaching within
_____ yards of Petitioner;
(g) That this Court make findings of fact and conclusions of law concerning the
issues in this case;
(h) That Petitioner have such other and further relief as the Court may deem just and
proper;
(i) That this Court issue Family Violence Ex Parte and Twelve Month Protective
Orders to:
Check the following paragraphs that apply to your case. Fill in the information needed by
each paragraph you check.
___ award Petitioner temporary sole legal and physical custody of the minor child/ren;
4
___ order Respondent to vacate the family residence at ____________________________
_______________ instanter;
___ grant Petitioner exclusive temporary use and possession of the family residence at _____
__________________________________ and all personal property of the parties located
at the family residence and Petitioner’s current residence with the exception of
Respondent’s personal clothing; that law enforcement ________________ (sheriff or
police department) assist Petitioner in returning to the family residence and in ensuring
that the Respondent vacates said residence and that all keys, garage door openers and
other security devices to the family residence are secured and given to the Petitioner;
___ order Respondent to provide suitable alternate housing for Petitioner and/or Petitioner’s
children;
___ order Respondent to stay away from Petitioner’s and /or Petitioner’s minor child/ren’s
place of residence, place of employment, and/or school;
___ order Respondent ’ s visitation with the minor child/ren be limited to no visitation or
________________________________________________________________________
________________________________________________________________________
_;
___ order Respondent to pay to Petitioner child support for the minor child/ren;
___ order Respondent to pay spousal support for Petitioner;
___ award the Petitioner costs and attorney’s fees for having to bring this action;
___ order that Petitioner’s current address be kept confidential;
___ enjoin and restrain Respondent from selling, disposing or encumbering, trading,
contracting to sell, or otherwise disposing or removing from the jurisdiction of this Court
any of the property of Petitioner or of the parties except in the ordinary course of
business;
___ enjoin and restrain Respondent from disconnecting the home utilities, changing and/or
canceling auto, health or life insurance for Respondent, Petitioner, and/or the Petitioner’s
minor child/ren, and/or interfering with Petitioner’s or the Petitioner’s minor child/ren’s
mail;
___ grant Petitioner the use of the following automobile: Make________, Model ________,
Year____, and law enforcement ___________(sheriff or police department) ensure that
all keys to said vehicle be immediately returned to Petitioner;
___ permit Petitioner to remove the following property from the residence for the exclusive
use by Petitioner and/or the minor child/ren
5
________________________________________
________________________________________________________________________
_
________________________________________________________________________
_
and law enforcement _____________(sheriff or police department) be ordered to assist
the Petitioner during this removal;
___ order Respondent to undergo evaluation for drug/alcohol abuse and to follow the
recommended treatment;
___ order Respondent to undergo a batterer’s intervention program and to follow the
recommended treatment;
___ order Respondent to return
__________________________________________________
_________________ to Petitioner immediately;
___ order Respondent to reimburse Petitioner for damages or expenses for the
following:____
________________________________________________________________________
___ order additional relief as follows:
_______________________________________________
________________________________________________________________________
_
Respectfully submitted,
______________________________
Address ______________________ Petitioner
_____________________________
Phone________________________
(Do not give current address if confidential,
give alternative address)
Respondent Identifying Fact Sheet
Complete as much as possible
Respondent’s social security number is __________________, date of birth is _________, sex
___, color of hair ___________, color of eyes ______________, height _______, weight _____.
Respondent’s race is ______. Ethnic background ____________ Respondent drives a
_____________________, license tag number _________________ and has a ____(state) driver’s
license number ___________. Respondent has distinguishing marks (tattoos, scars,
etc.)_____________________. Respondent’s home address ______________________________.
and is employed by________________ at _______________________ and works from ____ to
____ on (days)___________.
6
THE SUPERIOR COURT FOR THE COUNTY OF_______________
STATE OF GEORGIA
_____________________, ]
Petitioner, ] Civil Action File
]
5. ] No.
____________
]
_____________________, ]
Respondent. ]
VERIFICATION
Personally appeared _____________________, who being duly sworn states that she/he
is the Petitioner in the above styled case and that the facts set forth in the foregoing Petition for
Temporary Protective Order are true and correct.
______________________________
Petitioner
Sworn and subscribed before
me this _____ day of _____________, ________.
_______________________________
NOTARY PUBLIC
My commission expires:
* REMOVE THIS PAGE FROM PETITION *
Pursuant to O.C.G.A. ' 19-13-3
Petitioner assisted by
Name __________________________
Address ________________________
_______________________________
Phone __________________________
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