Fill and Sign the New York Order Protection Form

F.C.A. §§ 304.2, 740 General Form 6 (Temporary Order of Protection: PINS; Juvenile Delinquency) 12/2013 At a Term of the Family Court County of , State of New York (address) PRESENT: Hon _________________________________________ In the Matter of a Proceeding under Article of the Family Court Act TEMPORARY ORDER OF PROTECTION [Articles 3 and 7] Docket No. Family Unit No. (check one) □Ex Parte Respondent □ Respondent present in court __________________________________________ NOTICE: YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY SUBJECT YOU TO FAMILY COURT PROSECUTION AND DETENTION. IF YOU FAIL TO APPEAR IN COURT WHEN YOU ARE REQUIRED TO DO SO, THIS ORDER MAY BE EXTENDED IN YOUR ABSENCE AND THEN CONTINUES IN EFFECT UNTIL A NEW DATE SET BY THE COURT. THIS ORDER OF PROTECTION WILL REMAIN IN EFFECT EVEN IF THE PROTECTED PARTY HAS, OR CONSENTS TO HAVE, CONTACT OR COMMUNICATION WITH THE PARTY AGAINST WHOM THE ORDER IS ISSUED. THIS ORDER OF PROTECTION CAN ONLY BE MODIFIED OR TERMINATED BY THE COURT. THE PROTECTED PARTY CANNOT BE HELD TO VIOLATE THIS ORDER NOR BE ARRESTED FOR VIOLATING THIS ORDER . Whereas the Family Court has made a determination in accordance with [check applicable box]: □ Article 3 (juvenile delinquency) □ Article 7 (Person in Need of Supervision) of the Family Court Act, and the Respondent having been [check applicable box]: present in Court and advised of the issuance and contents of❑ this Order not present in Court, and good cause having been shown, ❑ Now, therefore, it is hereby ordered that [specify first name, middle initial and last name] _____________ __________________the above-named Respondent, observe the following conditions of behavior: Check Applicable Box(es): □ Stay away from □ [name(s) of protected person(s)] ______________________________________ and/or from the □ home of □ school of ___________________ □ business of □ place of employment of __________________ □ other [specify]: ; □ Refrain from harassing, intimidating, threatening or otherwise interfering with [specify victim(s) or members of victim's family or household] ; Refrain from intentionally injuring or killing without justification the following companion ❑ animal (s) (pet(s)) [specify type(s) and, if available, name(s)]: ______________________________ ________________________________________________________________________________ [The following paragraphs apply only to Article 7 orders of protection; check applicable box(es)]: □ Refrain from assault, stalking, harassment, aggravated harassment, menacing, reckless endangerment, strangulation, criminal obstruction of breathing or circulation, disorderly conduct, criminal mischief, sexual abuse, sexual misconduct, forcible touching, intimidation, threats, identity theft, grand larceny, coercion 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)]: _______________________________________________________________________________; □ Refrain from (indicate acts of omission or commission): ________________________________ _____________________________that create an unreasonable risk to the health, safety or welfare of the Respondent; □ Permit [specify individual]: , entitled by court order or separation agreement, to visit with the Respondent child during the following periods of time [specify] ; under the following terms and conditions [specify]: ; □ Participate in family counseling or other professional counseling activities, or other services, including alternative dispute resolution services, deemed necessary for the rehabilitation of the Respondent and not contrary to Respondent’s religious beliefs, conducted by an authorized person or agency to which the Respondent has been referred [specify program or services]: ; □ Permit [specify individual] to enter the residence during [specify date/time] to remove personal belongings not in issue in this or any other litigation; □ Pay or provide access to health or medical insurance for necessary medical care and treatment arising from the incident or incidents forming the basis of the order [specify beneficiary of treatment and coverage] ; □ Custody of respondent during the term of this order is awarded to [specify individual] ___________________________________________under the following terms and conditions [specify]: ____________________________________________________________________ [The following paragraphs apply to ALL orders]: □ Observe other condition(s) as are necessary to further the purposes of protection [specify conditions]: It is further ordered that this order of protection shall remain in force until and including [specify]: ____________________________________________________ , but if you fail to appear in court when you are required to do so, the order may be extended and continue in effect until a new date set by the Court. 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 APPELLANT BY THE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT, WHICHEVER IS EARLIEST. ENTER Date: __________________________________ Judge of the Family Court. Check Applicable Box(es): Party against whom order was issued was advised 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]: ❏ ❏ ADDITIONAL SERVICE INFORMATION [specify]:_______________________________________