Fill and Sign the Petitioner First Middle Last Name Form

Order for Protection (ORPRT) - Page 1 of 6 WPF DV -3.015 Mandatory (07/2019) - RCW 26.50.060, RCW 9.41.800 Court of Washington For Order for Protection No . Court Address Telephone Number: ( ) (Clerk's Action Required) (ORPRT) _________________________________ _______ Petitioner (First, Middle, Last Name) DOB vs. _________________________________ _______ Respondent (First, Middle, Last Name) DOB Names of Minors : [ ] No Minors Involved Respondent Identifiers (List first, middle and last name/s and age/s) _____________________________________ _____________________________________ _____________________________________ _____________________________________ Access to weapons : [ ] yes [ ] no [ ] unkn own Sex Race Hair Height Weight Eyes 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 [ ] appeared [ ] did not appear . This order is issued in accordance with the Full Faith and Credit provisions of VAWA: 18 U.S.C. § 2265. Respondent and the victim are : [ ] Intimate Partners because they are: [ ] current or former spouses or domestic partners, [ ] parents of a child -in-common, [ ] age 16 or older and are/were in a dating relationship, and are currently residing together or resided together in the past, [ ] age 16 or older and are/were in a dating relationship, but have never resided together. [ ] Family or household members because they are: [ ] current or former adult cohabitants as roommates, [ ] adult in-laws, [ ] adults related by blood, [ ] parent and child, [ ] stepparent and stepchild, [ ] grandparent and grandchild Respondent committed domestic violence as defined in RCW 26.50.010. Credible Threat : [ ] 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 fol lowing pages): [ ] Respondent is restrained from committing acts of abuse as listed in provisions 1 and 2, on page 2. [ ] No -contact provisions apply. [ ] 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 (07/2019) - 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 you and the petitioner are current or former spouses or domestic partners, parents of a child -in-common, age 16 or older and are/were in a dating relationship , and are currently residing together or resided together in the past, age 16 or older and are/were in a dating relationship, but have never resided together , you will not be able to own or possess a firearm, other dangerous weapon, ammunition, or conceale d 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 [ ] residence [ ] workplace [ ] school; [ ] the day care or school of [ ] the minors named in the table on page one [ ] these min ors only: [ ] Other: Order for Protection (ORPRT) - Page 3 of 6 WPF DV -3.015 Mandatory (07/2019) - 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 jurisdiction 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. To comply with the Child Relocation Act, anyone with majority or substantially equal residential time (at least 45 percent) w ho wants to move with the child must notify every other person who has cour t-ordered time with the child . Specific exemptions from notification may be available if the court finds unreasonable risk to health or safety. 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 mi nors 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: Order for Protection (ORPRT) - Page 4 of 6 WPF DV -3.015 Mandatory (07/2019) - RCW 26.50.060, RCW 9.41.800 [ ] 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: [ ] 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 access, possess or obtain any firearms, other dangerous weapons, or concealed pistol license s; and  comply with the Order to Surrender Weapons filed separately. (Note: Also use form All Cases 02.050 .) 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 per son: [ ] has used, displayed, or threatened to use a firearm or other dangerous weapon in a felony; or [ ] is ineligible to possess a firearm under RCW 9.41.040. Order for Protection (ORPRT) - Page 5 of 6 WPF DV -3.015 Mandatory (07/2019) - RCW 26.50.060, RCW 9.41.800 [ ] may issue the orders referred to above because the court finds by a preponderance 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 felony; or [ ] is 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 boundar y 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 c lass 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 prot ection 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 o f 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 Ord er’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 Co lumbia, 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 electronically forward a copy of this order , and any order to surrender weapons, 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 t his court proof of service. [ ] Respondent appeared and was informed of the order by the court; further service is not required. [ ] Petitioner shall serve this order by [ ] mail [ ] publication. [ ] (Only if surrender of weapons not ordered ) Petitioner shall make private arrangements for service of this order. Order for Protection (ORPRT) - Page 6 of 6 WPF DV -3.015 Mandatory (07/2019) - 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, ab ove. [ ] 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 : The law allows you to register for certain notifications regarding this protection order and its status. Visit www.RegisterVPO.com or call 1 -877 -242 -4055 for more information or to sign up. If you feel that you are in danger, call 9 -1-1 immediately. Petitioner or Petitioner’s Lawyer must complete a Law Enforcement Information Sheet (LEIS).