Fill and Sign the Plaintiffs Guide Sheet for Protective Orders Mohave County Form

Effective: January 2007 Page 1 of 2 Adopted by Administrative Directive No. 2006-01\ All Courts in Arizona/NCIC#/DPS# Address City, Arizona Zip Code Telephone Number Plaintiff / Plaintiff Employer (Work Injunction ONLY) Birth Date: Agent’s Name (Work Injunction ONLY) Defendant Address City, State, Zip Code, Phone Case No. PETITION for [ ] Order of Protection [ ] Injunction Against Harassment [ ] Workplace Injunction DIRECTIONS: Please read the Pl aintiff’s Guide Sheet before filling out this form. 1. Defendant/Plaintiff Relationship: [ ] Married now or in t he past [ ] Live together now or lived together in the past, [ ] Child in common [ ] One of us pregnant by the ot her [ ] Related (Parent, In-law, Brother, Sister or Grandparent) [ ] Dating-never lived together [ ] Other: 2. [ ] If checked, there is a pending action involving mate rnity, paternity, annulment, legal separation, dissolution, custody, parenting time or support in Superior Court, Case #: . (COUNTY) 3. Have you or the Defendant been charged or arrested for domestic violence OR requested a Protective Order? [ ] Yes [ ] No [ ] Not sure If yes or not sure, explain: 4. I need a Court Order because: (PRINT both the date(s) and briefly what happened): Date(s) Describe what happened (Attach additional paper if necessary – Do not write on back) Case No. ____________________ Effective: January 2007 Page 2 of 2 Adopted by Administrative Directive No. 2006-01 \ 5. The following persons should also be on this Order. As stated in number 4, the Defendant is a danger to them: (___/___/_____) (___/___/_____) Birth Date Birth Date (___/___/_____) (___/___/_____) Birth Date Birth Date 6. Defendant should be ordered to stay away from these locations, at all times, even when I am not present: [ ] Home [ ] Work [ ] School/Others 7. [ ] If checked, because of the risk of harm, order the defendant NOT to possess firearms or ammunition. 8. [ ] If checked, request an order for the Defendant to participate in domestic violence counseling or other counseling. 9. Other: Under penalty of perjury, I swear or affirm the above statements are true to the best of my knowledge, and I request an Order / Injunction granti ng relief as allowed by law. Attest: ___/___/_____ Plaintiff Judicial Officer/ Clerk / Notary Date