Fill and Sign the Optional Use First Name Middle Last Name Respondent Form

Order for Protection (ORPRT) - Page 1 of 6 WPF DV-3.015 Mandatory (08/2017) - RCW 26.50.060, RCW 9.41.800 Court of Washington For _________________________________ _______ Petitioner (First, Middle, Last Name) DOB vs. _________________________________ _______ Respondent (First, Middle, Last Name) DOB Order for Protection No. Court Address Telephone Number:( ) (Clerk's Action Required) (ORPRT) Names of Minors : No Minors Involved Respondent Identifiers Sex Race Hair Height Weight Eyes (List first, middle and last name/s and age/s) _____________________________________ _____________________________________ _____________________________________ _____________________________________ Caution: Access to weapons : yes no unknown Respondent’s Distinguishing Features : _____________________________________ _ The Court Finds Based Upon the Court Record : The court has jurisdiction over the parties, the minors, and the subject matter. Respondent had reasonable notice and an opportunity to be heard. Notice of this hearing was served on the respondent by personal service service by mail pursuant to court order service by publication pursuant to court order other . Respondent received actual notice of the hearing. Respondent was was not present at the hearing. This order is issued in accordance with the Full Faith and Credit provisions of VAWA: 18 U.S.C. § 2265. Respondent’s relationship to the victim is: spouse or former spouse current or former dating relationship in -law parent or child parent of a child in common stepparent or stepchild blood relation other than parent or child current or former domestic partner current or former cohabitant as ro ommate current or former cohabitant as part of a dating relationship Respondent committed domestic violence as defined in RCW 26.50.010. Respondent represents a credible threat to the physical safety of the protected person/s. Additional findings may be found below. The court concludes that the relief below shall be granted. Court Order Summary (additional provisions are listed on the following pages): Respondent is restrained from committing acts of abuse as listed in provisions 1 and 2, on page 2. No-contact provisions apply as set forth on the following pages. Prohibition and surrender of weapons apply. This order is effective immediately and for one year from today’s date, unless stated otherwise here (date) : Order for Protection (ORPRT) - Page 2 of 6 WPF DV-3.015 Mandatory (08/2017) - RCW 26.50.060, RCW 9.41.800 It is Ordered: 1. Respondent is restrained from causing physical harm, bodily injury, assault, including sexual assault, and from molesting, harassing, threatening, or stalking petitioner the minors named in the table above these minors only: (Respondent: If the petitioner is your spouse or former spouse, current or former domestic partner, the parent of a child in common, or a current or former cohabitant as part of a dating relationship, you will not be able to own or possess a firearm, other dangerous weapon, ammunition, or concealed pistol license under state or federal law for the duration of the order.) 2. Respondent is restrained from harassing, following, keeping under physical or electronic surveillance, cyberstalking as defined in RCW 9.61.260, and using telephonic, audiovisual, or other electronic means to monitor the actions, locations, or wire or electronic communication of petitioner the minors named in the table above only the minors listed below members of the victim’s household listed below the victim’s adult children listed below: 3. Respondent is restrained from coming near and from having any contact whatsoever, in person or through others, by phone, mail, or any means, directly or indirectly, except for mailing or service of process of court documents by a 3 rd party or contact by Respondent’s lawyer(s) with petitioner the minors named in the table above these minors only: If both parties are in the same location, respondent shall leave. 4. Respondent is excluded from petitioner's residence workplace school; the day care or school of the minors named in the table above these minors only: Other Petitioner's address is confidential. Petitioner waives confidentiality of the address which is: 5. Petitioner shall have exclusive right to the residence that petitioner and respondent share. The respondent shall immediately vacate the residence. The respondent may take respondent's personal clothing and tools of trade from the residence while a law enforcement officer is present. This address is confidential. Petitioner waives confidentiality of this address which is: 6. Respondent is prohibited from knowingly coming within, or knowingly remaining within ________________________ (distance) of: petitioner’s re sidence workplace school; the day care or school of the minors named in the table on page one these minors only: Other: Order for Protection (ORPRT) - Page 3 of 6 WPF DV-3.015 Mandatory (08/2017) - RCW 26.50.060, RCW 9.41.800 7. Petitioner shall have possession of essential personal belongings, including the following: 8. Petitioner is granted use of the following vehicle: Year, Make & Model_____________________________________ License No. 9. Other: Protection for minors : This state has exclusive continuing jurisdiction; is the home state; has temporary emergency jurisdiction that may become final jurisdict ion under RCW 26.27.231(2); other: ___________________________________________ 10. Petitioner is granted the temporary care, custody, and control of the minors named in the table above these minors only: The respondent will be allowed visitations as follows: Petitioner may request modification of visitation if respondent fails to comply with treatment or counseling as ordered by the court. If the person with whom the child resides a majority of the time plans to relocate the chi ld, that person must comply with the notice requirements of the Child Relocation Act . Persons entitled to time with the child under a court order may object to the proposed relocation . See RCW 26.09, RCW 26.10 or RCW 26.26 for more information . 11. Respondent is restrained from interfering with petitioner's physical or legal custody of the minors named in the table above these minors only: 12. Respondent is restrained from removing from the state the minors named in the table above these minors only: Additional requests: 13. Respondent shall participate in treatment and counseling as follows: domestic violence perpetrator treatment program approved under RCW 26.50.150 or counseling at: parenting classes at: drug/alcohol treatment at: other: Order for Protection (ORPRT) - Page 4 of 6 WPF DV-3.015 Mandatory (08/2017) - RCW 26.50.060, RCW 9.41.800 14. Petitioner is granted judgment against respondent as provided in the Judgment, WPF DV 3.030. 15. Parties shall return to court on _______________________, at __________ ___.m. for review. Protection for pets : 16. Petitioner shall have exclusive custody and control of the following pet(s) owned, possessed, leased, kept, or held by petitioner, respondent, or a minor child residing with either the petitioner or the respondent. (Specify name of pet and type of animal): ____________________________________________________________________. 17. Respondent is prohibited from interfering with the protected person’s efforts to remove the pet(s) named above. 18. Respondent is prohibited from knowingly coming within, or knowingly remaining within _______________ (distance) of the following locations where the pet(s) are regularly found: petitioner's residence (You have a right to keep your residential address confidential .) ___________________________________________________________ Park other:___________________________________________________________ Prohibit Weapons and Order Surrender The Respondent must:  not possess or obtain any firearms, other dangerous weapons, or con cealed pistol license; and  comply with the Order to Surrender Weapons filed separately. Findings – The court (check all that apply): must issue the orders referred to above because : the first restraint provision is ordered above, and the court found on page one that the Respondent had actual notice, represented a credible threat, and was an intimate partner . Respondent: If the court checked this box, then effective immediately, and continuing as long as this protection order is in effect, you may not possess a firearm under state law. Violation is a felony. RCW 9.41.040(2). the court finds by clear and convincing evidence that the restrained person has: used, displayed, or threatened to use a firearm or other dangerous weapon in a felony; or previously committed an offense making him or her ineligible to possess a firearm under RCW 9.41.040. may issue the orders referred to above because the court finds by a p reponderance of evidence, the Respondent : presents a serious and imminent threat to public health or safety, or the health or safety of any individual by possessing a firearm or other dangerous weapon; or has used, displayed or threatened to use a firearm or other dangerous weapon in a Order for Protection (ORPRT) - Page 5 of 6 WPF DV-3.015 Mandatory (08/2017) - RCW 26.50.060, RCW 9.41.800 felony; or previously committed an offense making him or her ineligible to possess a firearm under RCW 9.41.040. Warnings to the Respondent : A violation of provisions 1 through 6 of this order with actual notice of its terms is a criminal offense under chapter 26.50 RCW and will subject you to arrest. If the violation of the protection order involves travel across a state line or the boundary of a tribal jurisdiction, or involves conduct within the special maritime and territorial jurisdiction of the United States, which includes tribal lands,you may be subject to criminal prosecution in federal court under 18 U.S.C. §§ 2261, 2261A, or 2262. A violation of provisions 1 through 6, 17, or 18 of this order is a gross misdemeanor unless one of the following conditions apply: Any assault that is a violation of this order and that does not amount to assault in the first degree or second degree under RCW 9A.36.011 or 9A.36.021 is a class C felony. Any conduct in violation of this order that is reckless and creates a substantial risk of death or serious physical injury to another person is a class C felony. Also, a violation of this order is a class C felony if you have at least two previous convictions for violating a protection order issued under Titles 7, 10, 26 or 74 RCW. If your relationship to the victim is as intimate partner, then effective immediately, and continuing as long as this protection order is in effect, you may not possess a firearm or ammunition under federal law . 18 U.S.C. § 922(g)(8). A violation of this federal firearms law carries a maximum possible penalty of 10 years in prison and a $250,000 fine. If you are convicted of an offense of domestic violence, you will be forbidden for life from possessing a firearm or ammunition. 18 U.S.C. § 922(g)(9); RCW 9.41.040. You Can Be Arrested Even if the Person or Persons Who Obtained the Order Invite or Allow You to Violate the Order’s Prohibitions . You have the sole responsibility to avoid or refrain from violating the order’s provisions. Only the court can change the order upon written application. Pursuant to 18 U.S.C. § 2265, a court in any of the 50 states, the District of Columbia, Puerto Rico, any United States territory, and any tribal land within the United States shall accord full faith and credit to the order. Warning: A person may be guilty of custodial interference in the second degree if they violate provisions 10, 11, or 12. Washington Crime Information Center (WACIC) Data Entry It is further ordered that the clerk of the court shall forward a copy of this order on or before the next judicial day to _____________________________________________ County Sheriff's Office City Police Department where petitioner lives which shall enter it into WACIC. Service The clerk of the court shall also forward a copy of this order on or before the next judicial day to County Sheriff's Office City Police Department where respondent lives which shall personally serve the respondent with a copy of this order and shall promptly complete and return to this court proof of service. Petitioner shall serve this order by mail publication. Petitioner shall make private arrangements for service of this order. Respondent appeared and was informed of the order by the court; further service is not required. Order for Protection (ORPRT) - Page 6 of 6 WPF DV-3.015 Mandatory (08/2017) - RCW 26.50.060, RCW 9.41.800 Law Enforcement Assistance Law enforcement shall assist petitioner in obtaining: Possession of petitioner's residence personal belongings located at: the shared residence respondent’s residence other: _________________________ Custody of the above-named minors, including taking physical custody for delivery to petitioner. Possession of the vehicle designated in paragraph 7, above. Other: ___________________________________________________________ Other: This order is in effect until the expiration date on page one . If the duration of this order exceeds one year, the court finds that an order of one year or less will be insufficient to prevent further acts of domestic violence. Other: Dated: __________________________________ at ______________________ a.m./p.m. Judge/Commissioner I acknowledge receipt of a copy of this Order:  ______________________________________ Signature of Respondent/Lawyer WSBA No. Print Name  Signature of Petitioner/Lawyer WSBA No. Print Name Petitioner or Petitioner’s Lawyer must complete a Law Enforcement Information Sheet (LEIS).