Fill and Sign the Protective Order Forms Arizona Judicial Branch

Page 1 of 2 Approved: August 2001Petition for Injunction Against Harassment: A.R.S. §§ 12-1809 (A)\ , (D); 12-284; 22-281; 22-404 COURTS OF ARIZONA - NAME OF COURT Street Address City, Ariz\ ona Zip Code Phone Number Plaintiff Date of Birth \ Defendant \ Address \ City, State, Zip Code, Telephone PETITION FOR INJUNCTION AGAINST HARASSMENT MODIFIED Case Number NOTE: NO FILING FEES, but Service Fees May Be Waived or Deferred If You \ Are Unable to Pay 1. My relationship to the defendant is: \ . 2. Harassment involves a series of acts. The acts must have occurred withi\ n the past year unless the Defendant has been incarcerated or out of state. I have been harassed by the Defendan\ t as follows (be as specific as possible, giving the date or approximate date for each action): Date(s) Describe what happened 3 Is there or has there been any court case or court order that involves s\ imilar conduct by you and/or the Defendant? No Yes: If known: date, name of court, facts of case: \ \ \ \ 4. If the Court does not grant your request today, without notice to the De\ fendant, what serious harm may occur: \ \ 5.I ask this Court to order the Defendant not to commit an act of harassme\ nt against me and/or persons named below and/or against my property AND make the following Order(s) (check whi\ ch orders you want): Waive or defer any service fees. Order the Defendant not to contact me: in person; by phone; in writing; DESCRIPTION OF DEFENDANTSEX RACEDATE OF BIRTHHEIGHT WEIGHT EYESHAIR SOC.SEC.NO. ALIAS (if known): \ Defendant is: Military Law Enforcement Page 2 of 2 Approved: August 2001Petition for Injunction Against Harassment: A.R.S. §§ 12-1809 (A)\ , (D); 12-284; 22-281; 22-404 DO NOT FILL OUT ADDRESSES AND/OR PHONE NUMBERS BELOW IF YOU WANT THEM \ KEPT PRIVATE The following persons should be included within the protection of this O\ rder for the following reasons: Name and Address if different than yours (do not include yourself) Relationship to you D.O.B. Reason(s) Name: Address: Name: Address: Name: Address: Keep my address private. (Do not check this box if the Defendant knows \ where you live.) Order the Defendant not to come on or near (LEAVE NEXT LINE BLANK IF BO\ X ABOVE IS CHECKED): My residence at: \ My place of employment (Name and Address): \ Does the Defendant also work there? Yes No School (Name and Address): \ Other address: \ \ Other requests: \ \ \ \ My Signature Date Attorney’s Signature Date V E R I F I C A T I O N I swear or affirm that the contents of this Petition are true to the bes\ t of my knowledge. \ Plaintiff or Third Party \ SUBSCRIBED AND SWORN to before me on \ Judicial Officer/Clerk/Notary Date