Fill and Sign the Order Protection Form

F.C.A. 446, 551, 656, 842 & 1056 General Form 5a 12/2013 ORI No: At a Term of the Court Order No: County of , State of New York NYSID No:- (address) PRESENT: Hon. In the Matter of a Proceeding under ORDER OF PROTECTION Article Of the Family Court Act [Articles 4, 5, 6, 8 and 10] Docket No. _________________________ Petitioner Family Unit No. _____________________ Date of Birth: (check one)  Upon Default v.  Both Parties Present In Court Respondent Date of Birth: _______________________________________________ NOTICE: YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY SUBJECT YOU TO MANDATORY ARREST AND CRIMINAL PROSECUTION, WHICH MAY RESULT IN YOUR INCARCERATION FOR UP TO SEVEN YEARS FOR CRIMINAL CONTEMPT, AND/OR MAY SUBJECT YOU TO FAMILY COURT PROSECUTION AND INCARCERATION FOR UP TO SIX MONTHS FOR CONTEMPT OF 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 . __________________________________________________________ A petition under Article of the Family Court Act, sworn to on , having been filed in this Court in the above-entitled proceeding,, 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 this Court [check applicable box]:  after hearing  on consent , having determined that good cause has been shown for the issuance of this Order, NOW, THEREFORE, IT IS HEREBY ORDERED that [specify first name, middle initial and last name]: ___ _____________________________________________________must observe the following conditions of behavior: (Check Applicable Paragraphs and Subparagraphs) : [01]  Stay away from [A]  [name(s) of protected person(s)]: ____________________________________________ and/or from the [B]  home of , [C]  school of _______________________________________________________________, [D]  business of _____________________________________________________________, [E]  place of employment of ___________________________________________________, [F]  other [specify location] ____________________________________________________, [14  Refrain from communication or any other contact or by mail, telephone, e-mail, voice-mail or other electronic or any other means with [specify protected person(s)]: ; [02]  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)]: ; [15]  Refrain from intentionally injuring or killing without justification the following companion animal(s) (pet(s)) [specify type(s) and, if available, name(s)]: ; [11]  Permit [specify individual]: to enter the residence at [specify]: _________ _________________________________________during [specify date/time]: with [specify law enforcement agency, if any]: to remove personal belongings not in issue in litigation [specify items]: ; [04]  Refrain from [indicate acts]: ________________________________________________________________ that create an unreasonable risk to the health, safety or welfare of [specify child(ren), family or household member(s) ]: ________________________________________________________________________________________________; [05]  Permit [specify individual] : , entitled by a court order or separation or other written agreement to visit with [specify child(ren)]: ___________________________________________________ during the following periods of time [specify]: under the following terms and conditions [specify]: ; [07]  Custody of [specify child(ren)]: shall be awarded to [specify individual]: under the following terms and conditions [specify]: _____________ _____________________________________________________________________________ ; [12] Surrender any and all handguns, pistols, revolvers, rifles, shotguns and other firearms owned or possessed, ❑ including, but not limited to, the following: and do not obtain any further guns or other firearms. Such surrender shall take place immediately, but in no event later than [specify date/time] : ____________ at [specify location]: ; [ ] Promptly return or transfer the following identification documents specify]: ______________________________ ❏ ____________________________________________________________________________________to the party protected by this Order NOT LATER THAN [specify date]: in the following manner [specify manner or mode of return or transfer]: ____________________________________________ [Check box(es) if applicable]: Such documents shall be made available for use as evidence in this judicial ❏ proceeding. [Jointly owned documents or documents in both parties’ names only]: The ❏ following document(s) may be used as necessary for legitimate use by the Respondent [specify]: . 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] _________________ ________________________________________________________________________________________________; Arts. 5,6&8 only Pay counsel fees (and/or) any costs associated with the order to [specify person and terms] ❑ ____ __________________________________________________________________________________________________; Arts. 4,5&6 only Participate in an educational program, (and pay the costs thereof)[(specify program] __________ ❑ __________________________________________________________________________________________________; Art. 8 only Participate in a batterer's education program designed to help end violent behavior (and pay the ❑ costs thereof)[specify program] ; Art. 8 only Pay to the petitioner/victim(s) restitution, as follows [specify terms and amount up to $1 0,000]: ❑ ______________________________________________________________________________________________; and [99] Observe such other condition(s) as are necessary to further the purposes of protection [specify conditions]: ❑ ___________________________________________________________________________________________________; Art. 8 only [check if applicable]: Respondent is on probation [FCA§842 requires order to state if Respondent is on ❑ probation]. AGGRAVATING CIRCUMSTANCES FINDING [check box and fill in if applicable]: The court has made a finding on the record of the existence of the following ❑ AGGRAVATING CIRCUMSTANCES: _________________________________________________________________________ ____________________________________________________________________________________________ It is further ordered that the above-named Respondent's license to carry, possess, repair, sell or otherwise dispose of a firearm or firearms, if any, pursuant to Penal Law ' 400.00, is [check applicable box(es)]: [13A]  suspended, or [13B] revoked, (note: final order only) and/or [13C] ❑  the Respondent shall remain ineligible to receive a firearm license while this Order is in effect. It is further ordered that this order of protection shall remain in force until and including [specify date]: _______ The Family Court Act provides that presentation of a copy of this order of protection to any police officer or peace officer acting pursuant to his or her special duties authorizes, and sometimes requires, the officer to arrest a person who is alleged to have violated its terms and to bring him or her before the Court to face penalties authorized by law. Federal law requires that this order is effective outside, as well as inside, New York State. It must be honored and enforced by state and tribal courts, including courts of a state, the District of Columbia, a commonwealth, territory or possession of the United States, if the person restrained by the order is an intimate partner of the protected party and has or will be afforded reasonable notice and opportunity to be heard in accordance with state law sufficient to protect due process will be afforded reasonable notice and opportunity to be heard in accordance with state law sufficient to protect due process rights (18 U.S.C. § 2265, 2266). It is a federal crime to : • cross state lines to violate this order or to stalk, harass or commit domestic violence against an intimate partner or family member; • buy, possess or transfer a handgun, rifle, shotgun or other firearm or ammunition while this Order remains in effect (Note: there is a limited exception for military or law enforcement officers but only while they are on duty) ; and • buy, possess or transfer a handgun, rifle, shotgun or other firearm or ammunition after a conviction of a domestic violence-related crime involving the use or attempted use of physical force or a deadly weapon against an intimate partner or family member, even after this Order has expired.. (18 U.S.C. '' 922(g)(8), 922(g)(9), 2261, 2261A, 2262). Dated: _______________________________________ JUDGE OF THE FAMILY COURT COURT (COURT SEAL) 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. Check Applicable Box(es): Party against whom order was issued was present in Court and 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]: __________________________________________________________ ❏ [Modifications 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]: __________________________________________________________ ❏