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JV -2 4 5ATTO RNEY OR PA RTY WITHOUT ATTORN EY (N am e, St ate B ar nu mbe r, a nd add ress): FO R C OURT USE O NLY TEL EP HON E N O. (Op tion al) : FAX NO . ( Opt io na l) :: E-M AIL AD DR ESS (Op tio n al): ATTO RN EY F O R (N am e): S U PER IOR CO URT O F C ALIFO RNIA, C O UNTY O F STR EE T A D D RES S: MAI LIN G A D D RESS : CIT Y A N D ZIP C O DE: B RAN C H N AM E: CHILD'S NAME: CASE N UM BER S: JU VEN IL E: FA MILY : REL AT ED C AS ES ( if an y):A PP LIC AT IO N A ND A FFID AVIT F O R R ESTR AIN IN G O RDER — JU VEN IL E 1. The c h ild isa . a d ep enden t of t h e co urt un d er W elfar e a nd In stit u tio ns C ode se ctio n 3 00; o r b. th e s u bje ct o f a p etit io n th at h as b een fil e d in thi s co urt un der W elf a re a nd Ins tit u tio ns C ode s e ction 300; or c . a w ard o f th e c o urt u n de r W elfar e an d I n stit ut ion s C ode s e ctio n 60 1; ord. a w ard of t h e c o urt un de r W elfa re and I n stit ut io ns C ode s e ctio n 60 2; o re. th e s u bje ct o f a p etit io n th at h as b een fil e d in thi s co u rt un der W elf a re a nd Ins tit u tio ns C ode s e ction 601; or f . th e s u bje ct o f a p etit io n th at h as b een fil e d in thi s co urt un der W elf a re a nd Ins titu tio ns C ode s e ction 602. 2. Petit io ne r is thea . m oth er. g. p re se nt c ar eg iv e r of c h ild .b. fa th e r. h. c o urt- ap point ed s p ecial a dvo ca te.c . c h ild . i. r e pre se nta tiv e o f Ind ia n c h ild' s tr ib e.d . g ua rd ia n. j. o th e r ( s ta te int ere st or r e la tio ns hip to c h ild) :e. social worker . f. p rob atio n o ffic e r.3 . Pers o ns t o be p ro te cte d (L is t fu ll n am es an d a ges o f a ll p er so ns to be pro te ct ed; a ls o lis t re la tio nsh ip to c hi ld in it e m 1 ):N am e Age Rela tio ns hip to c h ild (s e lf , p are nt , leg al g uard ia n, cu rre nt ca re giv e r): 4. a. P ers o n to be re str a in ed ( fu ll n am e): b. DES C RIP TIO N:Sex: M F Ht.: W t. : H air c ol or: Ey e color : R ace : A ge : D ate of b ir th : 5. Th e p ers o n to be r e str a in ed h a s (c h ec k a t le ast o ne b ox):a . a ss a ult e d o r a tte m pted t o a ssa ult o ne or more of the pe rs on s t o b e p rot ecte d.b. c a u se d, t h re ate n ed , or at te m pted bo dil y in jur y on o ne o r m ore o f th e pers o ns to b e p ro te cte d. c . c a u se d o ne o r m ore o f th e p ers o ns to b e p ro te cted to fe a r p hysic a l o r e m otio nal h arm .d. s e xu ally a ssa ult e d o r a tte m pted to s e xu ally a ssa ult on e o r m ore o f th e p ers o n s to b e p ro tec te d. e . s ta lk ed one o r m ore o f th e pe rs on s to b e p ro tec te d.f. o th e r (s p ecif y ): a s d es crib ed in it e m 7 a s d es crib ed in at ta ch ed r e port b y: p olic e offic er s o cia l w ork e r p ro batio n o ffic er othe r Pag e 1 o f 3 Fo rm Ad opted for Ma nda tory Use APPLICATION AND AFFIDAVIT W elfa re an d Inst itut ion s C ode , §§ 213. 5, 21 3.7, 304, 34 5,Jud ic ial C oun cil o f C alif o rn ia 362.4 , 72 6.5; Fa mily C ode , §§ 6 218 , 63 20, 632 1, 6 322;JV -2 45 [R ev. J a nuary 1 , 2 0 07] FOR RESTRAINING ORDER—JUVENILE Penal C ode , § 1 36. 2; Ca l. Ru le s ofCRC, rules 5.620, 5.625, 5.630electronic form  2005 WWW.LawCA.com Law Publishers JV -24 5CAS E N AM E: CAS E N UM BER S: JUVENILE: FAMIL Y: 6. Req uest ed p erso nal c o nd uct or dersa. R estr a in ed p ers o n m us t n o t h ar as s, m ole st, a tta ck , str ik e , t h re ate n, a ssa ult (s exu all y or o th erw is e) , hi t, fo llo w , s ta lk , de str o y th e p ers o na l p ro perty o f, dis tu rb th e pea ce o f, k e ep u nd er su rv e illa nce , or b lock movem ents o f a ny p ers o n n am ed init e m 3 .b. R estr a in ed p ers o n m us t n o t co nta ct (e it h er d ir e ctly or in direc tly ), o r te lep hone, or s e nd m essa ges, m ail, or e- mail to an y p ers o n n am ed in it e m 3( 1 ) ex ce p t fo r b rie f an d p eace fu l c o nta ct as re qu ir e d for c o urt- o rd er ed vis itat io n of c h ild re n, un le ss a crim in al p rot ectiv e o rd er sa ys o the rw is e .(2 ) ex ce pt for p eace fu l w rit te n co nta ct th ro ugh a p ro ce ss se rv e r or a no the r p er so n to s e rv e le ga l pa pers r e la ted to a court case.c. Restr a in ed p ers o n m ust m ove im media te ly fr o m (ad dre ss): and ta ke on ly pe rs o nal c lo th in g a n d e ffe cts .d . R estr a in ed pers o n must sta y at le ast (s p ecif y ): ya rd s a w ay fr o m th e fo llo w in g p ers o n s and p la ce s(th e a dd re sse s o f th es e p la ce s a re o ptio na l a nd m ay b e k e p t co n fid entia l) :( 1 ) P ro te cte d pers o ns na med in it e m 3(2 ) P ro te cte d p ers o n 's r e sid e nc e (a d dr ess o ptio na l) : (3 ) P ro te cte d p ers o n 's p lac e of w ork ( a ddre ss o ptio na l): (4 ) T he ch ild 's s cho ol o r p la ce o f c h ild ca re (a ddre ss o pt ion al) : (5 ) P ro te cte d p ers o n 's ve h ic le ( de script ion o ptio nal) : (6 ) O th e r (s p ecif y ): (a dd re ss o ptio na l): e. A crim in al protectiv e o rd er o n Fo rm C R-1 60 is in e ffe ct: c as e nu m ber (s p ecif y ):(expiration date): (if m ore ord ers , lis t t h em in it e m i. ) .s p e cif y c o unty (if k n ow n): f. R es tr a in ed pe rs on m ust n ot ta ke a ny actio n to g et th e add re ss o r lo ca tio n o f any p ers o n n am ed in it e m 3 o r th e ad dr esse s or lo ca tio ns o f th e fa m ily mem bers , c a re giv e rs, or g uard ia ns o f any pe rs on s n am ed in it e m 3. (If it e m f is n ot checke d, t h e c o ur t h a s fo und good c a use n o t to m ake thi s o rd er .)P eac eful w rit ten c o nt act t h ro u gh a la w yer or th ro u gh a p ro ce ss s e rv er o r an oth e r pe rs on in orde r to s er ve le ga l p apers is allo w ed a n d do es no t vio lat e th is or der.g . R estr a ine d p ers o n m ust se ll or g iv e u p a ny fir ea rm s th a t h e o r s h e has o r co ntr o ls fo r a p erio d not to e xce ed th e d ura tio n o f th e re str a in in g o rd er. D escrib e in it e m 7 a ny u se of o r th re a t re ga rd in g u se o f fir e arm s. P et it io n er b e lie ve s th e r e str a in ed p ers o n has th e fo ll ow in g fir e arm s (s p e cif y): h. Th e c h ild is a w ar d or the su b je ct o f a petit io n un d er W elfar e and I n stit u tions Code se ctio n 6 0 1 o r 6 02 a nd m ust no t c o nt act, th re ate n, s tal k, o r dis tu rb th e p eace o f (lis t n am es): i. Oth er r e q ue ste d ord ers : JV-245 [Rev. January 1, 2007] APPLICATION AND AFFIDAVITPage 2 o f 3F O R R ESTR AIN IN G O RDER — JU VEN IL E JV -2 45C AS E N AM E: CAS E N UM BER S: JUVENILE: FAMIL Y: 7. Desc rip tio n of con du ct ( d es crib e in de ta il t h e most re ce nt in cid ents s u p po rting t h is applic atio n or a ttac h co p ie s of r e ports o f law enfo rc em en t o ffic e rs , s o cia l w ork e rs , p ro ba tion of fic e rs , or o th e r pro fe ss io nal p ers o ns): 8. Law e n fo rc em entT he f o llo win g la w e nfo rc e m en t a ge ncies must r e ce iv e c o pie s o f ord ers : La w e nfo rc e m en t a ge ncy Add re ss I d ec lare un der p enalty o f p erju ry u nder the laws o f th e Sta te of C al if o rn ia tha t th e fo re g o in g a nd a ll a tta ch m en ts a re tr u e a nd c o rre ct.D ate : (T YPE O R PR IN T N AM E) (SI GNATU RE O F P ETIT IO NER )JV-245 [Rev. January 1, 2007] APPLIC ATIO N A ND A FFID AVITPa g e 3 o f 3F O R R ESTR AIN IN G O RDER — JU VEN IL E