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1 ORI Number SC -15 THE SUPERIOR COURT FOR THE COUNTY O F STATE OF GEORGIA , : Petitioner, : Civil Action File v. : : , : No. ______________ Respondent. : FAMILY VIOLENCE EX PARTE PROTECTIVE ORDER The Petitioner having prayed pursuant to O.C.G.A. §§ 19 -13 -1 et seq ., that a Protective Order be issued; and alleged that Respondent has committed acts of Family Violence and that Petitioner is in reasonable fear of the Petitioner’s safety and the safety of Petitioner’s child/ren; and it appearing to the Court that probable cause exists that family violence has occurred in the past and may occur in the future, IT IS HEREBY ORDERED AND ADJUDGED: 1. That these proceedings be filed in the office of the Clerk of this Court. 2. That this Order applies in every county throughout the state and it shall be the duty of every court and every law enforcement official to enforce and carry out the provisions of this Order pursuant to O.C.G.A. § 19 -13 -4 (d). Law enforcement officers may use their arrest powers pursuant to O.C.G.A. §§ 19 -13 -6 and 17 -4-20 to enforce the terms of this Order. 3. That a copy of this Order be given to law enforcement and the Respondent be served with a copy of this Order and Petition for Temporary Protective Order instanter. 4. That the Respondent appear before this Court, on the day of , 20 at . m. in room of the County Courthouse at to show cause why the requests of the Petitioner should not be granted. 2 CIVIL ACTION FILE NO. 5. That Respondent is hereby enjoined and restrained from doing, or attempting [pco01] to do, or threatening to do, any act of injury, maltreating, molesting, following, harassing, harming or abusing the Petitioner and/or the minor child/ren in any manner. Respondent is not to interfere with Petitioner’s travel, transportation, or communication. Respondent shall not follow, place under surveillance, or contact the Petitioner at any place of the Petitioner for the purpose of harassing and intimidating the Petitioner. 6. That the Respondent is enjoined and restrained from doing or threatening to do [pco02] any act of injury, maltreating, molesting, harassing, harming, or abusing the Petitioner’s family or household. 7. That this Court determined that it had jurisdiction over the parties and the subject matter under the laws of the State of Georgia and the Court ordered that the Respondent be given reasonable notice and opportunity to be heard sufficient to protect the Respondent’s due process rights. This Order shall be presumed valid and pursuant to 18 U.S.C. § 2265(a) shall be accorded full faith and credit by any other state or local jurisdiction and shall be enforced as if an Order of the enforcing state or jurisdiction. ONLY THE FOLLOWING THAT ARE INITIALED BY THE JUDGE SHALL APPLY: 8. That until further Order by this Court, Petitioner is awarded sole and exclusive use [pco03] of the family residence at . 9. Respondent is ordered to leave the family residence immediately and law enforcement (sheriff or police department) is ordered to assist Petitioner in returning to the family residence and the removal of the Respondent. Respondent is to immediately surrender to law enforcement (sheriff or police department) all and any keys, garage door openers and other security devices to the family residence and law enforcement is to ensure that these are given to the Petitioner. 10. Respondent is ordered to provide suitable alternate housing for Petitioner and/or Petitioner’s children by . 11. Petitioner’s address is ordered to be kept confidential. 3 CIVIL ACTION FILE NO. 12. Respondent is ordered to stay away from Petitioner’s and Petitioner’s minor [pco04] child/ren’s residence at and workplace at or school and any subsequent residence or workplace or school of Petitioner and/or Petitioner’s minor child/ren. 13. That until further Order of this Court, Respondent is restrained and enjoined from [pco01,04] approaching within yards of Petitioner and/or Petitioner’s minor child/ren. 14. Respondent is ordered not to have any contact, direct, indirect or through another [pco05] person with Petitioner, by telephone, fax, e-mail or any other means of communication except as specified in this Order. 15. That Petitioner is awarded temporary custody of the minor child/ren, namely: [pco09] YOB sex YOB sex YOB sex YOB sex Respondent is ordered not to interfere with the physical custody of the child/ren. [pco06] Check here only if Respondent is awarded temporary custody of child/ren. 16. That Respondent is ordered to pay temporary child support for the minor child/ren to Petitioner in the amount of $ every beginning . All payments shall be made by or to: income deduction order child support receiver by mail directly to the Petitioner or 17. That Respondent is ordered to pay temporary support for the Petitioner in the amount of $ every beginning All payments shall be made by or to: income deduction order child support receiver by mail directly to the Petitioner or 4 CIVIL ACTION FILE NO. 18. That Respondent, only when accompanied by local law enforcement , shall be able to remove his/her clothing and personal items from the residence as follows: On , 20 at .m. 19. That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] is/are ordered not to sell, encumber, trade, damage, contract to sell, or otherwise dispose of or remove from the jurisdiction of this Court any of the property or pets of the Petitioner or joint property or pets of the parties except in the ordinary course of business. 20. That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] is/are ordered not to disconnect or have disconnected the home utilities, change or have changed and/or cancel or have canceled auto, health or life insurance for Respondent, Petitioner, and/or Petitioner’s child/ ren or interfere with Respondent, Petitioner’s and/or Petitioner’s child/ren’s mail. 21. That Petitioner is awarded temporary sole possession of the vehicle: Make Model Year Color . Respondent shall immediately surrender all keys, proof of insurance, and registration to this vehicle to law enforcement , and law enforcement shall immediately turn over said items to Petitioner. 22. That Petitioner shall be allowed to remove the following property from the family residence for Petitioner and/or Petitioner’s child/ren’s use : . On , 20 at law enforcement (sheriff or police department) is hereby ordered to assist the Petitioner during this removal. 23. That Respondent shall be required to return the following property for Petitioner and/or Petitioner’s children’s use : On , 20 at and law enforcement (sheriff or police department) is hereby ordered to assist the Petitioner during this return . CIVIL ACTION FILE NO. 5 24. It is further Ordered : [pco08] SO ORDERED this day of , 20 . JUDGE, SUPERIOR COURT _______________________ County _____________________________ Print or stamp Judge’s name Violation of the above Order may be punishable by arrest. CIVIL ACTION FILE NO. 6 NOTICE TO RESPONDENT 1. Violation of this Order may result in immediate arrest and criminal prosecution that may result in jail time and/or fines and/or may subject you to prosecution and penalties for contempt of court. 2. This Order shall remain in effect unless specifically superseded by a subsequent signed and filed Order, by operation of law, or by Order of dismissal, whichever occurs first. Only this Court can void, modify or dismiss this Order. Either party may ask this Court to change or dismiss this Order. 3. A person commits the offense of Aggravated Stalking when such person, in violation of a temporary or permanent protective Order prohibiting this behavior , follows, places under surveillance, or contacts Petitioner on public or private property for the purpose of harassing and intimidating the other person. This activity can subject the Respondent to arrest and prosecution for felony Aggravated Stalking, which carries penalties of imprisonment for not less than 1 year nor more than 10 years and a fine of up to $10,000.00. CIVIL ACTION FILE NO. Pursuant to O.C.G.A. § 19 -13 -3, Petitioner assisted by Name: Address: Telephone: Note to Judges: This form is promulgated as a Uniform Superior Court Rule under the auspices of O.C.G.A. § 19 -13 -53. To order a specific provision, please initial in the space provided. The court should delete or otherwise make inoperative any provision in the standardized form which is not supported by the evidence in the case and in order to comply with the court ’s application of the law and facts to an individual case. 7 CIVIL ACTION FILE NO. *REMOVE THIS PAGE FROM ORDER AND FILE SEPARATELY UNDER SEAL* *F or transmittal to the Georgia Protective Order Registry and, if applicable, the National Crime Information Center .* RESPONDENT’S IDENTIFYING FACT SHEET (please complete as much as possible; one of these must be provided to have the order placed in the National Crime Information Center registry: Respondent’s date of birth OR social security number) 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 has distinguishing marks (tattoos, scars, etc.)_____________________. Respondent drives a __________________________, license tag no:____________ (Expires: __ __) and has a ____(state) driver’s license no: _____________ (Expires: ____). Respondent’s home address _____________________________________________ and is employed by__________________ at _________________________________ and works from ____ to ____ on (days)___________. Respondent has the following known aliases: ____________________________. PROTECTED PARTIES’ IDENTIFYING INFORMATION Petitioner: _________________________ DOB ___________ sex _______ race ______________ Other: ___________ ______________ DOB ___________ sex _______ race ______________ Other: _________________________ DOB ___________ sex _______ race ______________ Other: _________________________ DOB ___________ sex _______ race ______________ Other: _________________________ DOB ___________ sex _______ race ______________ Transmitted to Georgia Protective Order Registry Date __________ Clerk ___________________________ Rev’d 8 / 14 CONFIDENTIAL INFORMATION FORM - ATTENTION COURT STAFF: THIS PAGE IS A RESTRICTED -ACCESS DOCUMENT . This document is not accessible to the public or to other parties. 8