Fill and Sign the Sc 16 Form

1 ORI Number ____________________ SC -16 THE SUPERIOR COURT FOR THE COUNTY OF ________________ STATE OF GEORGIA _____________________ , : Petitioner, : Civil Action File v. : _____________________ , : No. _____________________ Respondent. : FAMILY V IOLENCE TWELVE MONTH PROTECTIVE ORDER A hearing was held on this matter on ______________________, 20_____ for which the Respondent had notice as required by law and at which the Respondent appeared and/or had the opportunity to be heard and the Petitione r requested that the Protective Order entered in this case be continued. Having heard the evidence presented, reviewed the petition and the entire record concerning this case and for good cause shown, IT IS HEREBY ORDERED AND ADJUDGED: 1. That these pr oceedings be filed in the office of the Clerk of this Court. 2. That this Order applies in every county throughout the state and it shall be the duty of every court and every law enforcement official to enforce and carry out the provisions of this Order p ursuant to O.C.G.A. § 19 -13 -4 (d). Law enforcement officers may use their arrest powers pursuant to O.C.G.A. §§ 19 -13 -6 and 17 -4-20 to enforce the terms of this Order. 3. This Order shall be in effect for up to twelve (12) months from ________________ ______ , 20 _____ until ______________________ , 20_____. 4. That the Respondent has violated the Family Violence Act, O.C.G.A. § 19 -13 -1 [pco 01] et seq ., by committing family violence, has placed the Petitioner in reasonable fear for Petitioner’s safety, an d represents a credible threat to the physical safety of Petitioner and/or Petitioner’s child/ren. Respondent is hereby enjoined and restrained from doing, or attempting to do, or threatening to do, any act of injury, maltreating, molesting, following, har assing, harming, or abusing the Petitioner and/or the minor child/ren in any manner. Respondent is not to interfere with Petitioner’s travel, transportation, or communication. Respondent shall not follow, place under surveillance, or contact the Petition er at any place of the Petitioner for the purpose of harassing and intimidating the Petitioner. 5. That the Respondent is enjoined and restrained from doing or attempting to do, or [pco02 ] threatening to do, any act of injury, maltreating, molesting, harassing, harming, or abusing the Petitioner’s family or household. 2 CIVIL ACTION FILE NO. _____________________ 6. That this Court determined that it had jurisdiction over the parties and the subject matter under the laws of the State of Georgia and Re spondent received reasonable notice and had the opportunity to be heard before this Order was issued sufficient to protect the Respondent’s due process rights and this Order shall be presumed valid and pursuant to 18 U.S.C. § 2265(a) shall be accorded full faith and credit by any other state or local jurisdiction and shall be enforced as if an Order of the enforcing state or jurisdiction. ONLY THE FOLLOWING THAT ARE INITIALED BY THE JUDGE SHALL APPLY : _____ 7. Petitioner is awarded sole and exclusive p ossession of the residence at _________ __ _ [pco03] __________________________________ ____________________________ ______ _. _____ 8. Respondent is ordered to leave the family residence immediately and law enforcement at _____________ _____ (sheriff or poli ce department) is ordered to assist Petitioner in returning to the family residence and the removal of the Respondent. Respondent shall immediately surrender to law enforcement __________________ (sheriff or police department) all and any keys, garage doo r openers and other security devices to the family residence and law enforcement shall ensure that these are given to the Petitioner. _____ 9. Respondent is ordered to stay away from Petitioner’s and Petitioner’s child/ren’s [pco04 ] residence and workplac e and/or school and any subsequent residence or workplace or school of Petitioner and/or Petitioner’s minor child/ren. _____ 10. Respondent is ordered to provide suitable alternate housing for Petitioner and/or Petitioner’s children by ___________________ ___, 20_____. _____ 11. That Respondent is restrained and enjoined from approaching within ______ ____ yards [pco 01,04 ] of Petitioner and/or Petitioner’s minor children. _____ 12. Respondent is ordered not to have any contact, dir ect, i ndirect or through another [pco05 ] person with Petitioner, by telephone, fax, e -mail or any other means of communication except as specified in this Order. _____ 13. That Petitioner is awarded temporary custody of the minor child/ren, namely: [pco 09] __________________________________ YOB __________ __ sex ______ ____ __________________________________ YOB __________ __ sex ______ ____ __________________________________ YOB __________ __ sex ______ ____ ___________________ _______________ YOB __________ __ sex ______ ____ Respondent is ordered not to interfere with the physical custody of the minor child/ren. _____ [pco06 ] Initial here only if Respondent is awarded temporary custody of the child/ren. 3 CIVIL ACTION FILE NO. _____________________ ____ _ 14. The _____________ __ shall pay to the _______________ , for the support of the minor child/ren, the s um of _____ ____________________________ Dollars ($__________ _) per _____________________ ______ , beginning ______________________, 20_____ . All p ayments are to be made by or to: ____ income deduction order ____ child support receiver ____ by mail directly to the Petitioner or ____ _____________________________ _____ 15. Respondent is ordered to pay temporary support f or the Petitioner in the amount of $__________ _ every ______ _____________ beginning ______________________, 20_____. All pa yments are to be made by or to: ____ income deduction order ____ child support receiver ____ by mail directly to the Petit ioner or ____ _____________________________ _____ 16. Respondent shall have visitation with the minor child/ren according to the following schedule, beginning __________________ ______________________ : ____ no visitation ____ no visitation until ______________________, 20_____. ____ supervised visi tation, supervised by a third party as follows: ____________________________________________________________ _____________ _______________________________ ________ ________ ____ visitation every other weekend from Friday at 6 p.m. until Sunday at 6 p.m beginning_________________ ______________ _, ___________ ____ other visitation _________________________________________ ______ ____ circumstances concerning how Respondent shall pick u p and return the minor child/ren shall be ______________________________ _________ _ Strict compliance with this visitation provision shall not be a violation of the restraining provisions of this Order. _____ 17. Respondent, only when accompanie d by local law enforcement , shall be able to remove his/her clothing and personal items from the residence as follows: ________________________________________________________________ ______ _____________________________________________________________ _____ ____ On ______________________, 20_____ at ____ .m. _____ 18. (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] is/are ordered not to sell, encumber, trade, damage, contract to sell, or otherwise dispose of or rem ove from the jurisdiction of this Court any of the property or pets of the Petitioner or joint property or pets of the parties except in the ordinary course of business. 4 CIVIL ACTION FILE NO. _____________________ _____ 19. (Respondent)(Petit ioner)(both Respondent and Petitioner) [strike through appropriate] is/are ordered not to disconnect or have disconnected home utilities, change or have changed and/or cancel or have canceled auto, health or life insurance for Respondent, Petitioner, and/ or Petitioner’s child/ren or interfere with Respondent, Petitioner’s and/or Petitioner’s child/ren’s mail. _____ 20. Petitioner shall have sole, exclusive temporary possession of the vehicle: Make ____ ____________ Model ________________ Year ___ _ Color ____ _____ ___ . Respondent shall immediately surrender all keys, proof of insurance, and registration to this vehicle to law enforcement , and law enforcement shall immediately turn over said items to Petitioner. _____ 21. Petitioner shall be all owed to remove the following property from the family residence for Petitioner and/or Petitioner’s child/ren’s use : _____________________ __________ ______________________________________________________________________ _____________________________________ ________________________ _________ . On ___________________, 20_____ at ____ and law enforcement __________ __ __ (sheriff or police department) is hereby ordered to assist the Petitioner during this removal. _____ 22. Respondent is ordered to undergo alcoh ol/drug abuse evaluation and follow the recommended treatment. _____ 23. That Respondent shall be required to return the following property for Petitioner and/or Petitioner’s child/ren’s use : ____________________________ ____ _____________________________ ___________________ ______________________ On __________________, 20_____ at ____ .m. and law enforcement_______________ (sheriff or police department) is hereby ordered to assist the Petitioner during this return. _____ 24. Petitioner is awarded costs and attorney fees in the amount of _______________. _____ 25. FAMILY VIOLENCE INTERVENTION PROGRAM It is further Ordered that the Respondent shall make arrangements to begin a certified family violence intervention program (FVIP) within fou rteen (14) days of the signing of this Order, or if appropriate within fourteen (14) days upon release from incarceration. A list of local certified agencies will be given to the Respondent with this Order. Furthermore, Respondent shall appear before thi s court ___________________, 20_____ at .m. for a hearing on the status of his/her application, attendance and/or completion of the FVIP. At that hearing, Respondent is ordered to present to this court a written status report from the agency p roviding the certified FVIP. The status report shall detail Respondent ’s application, attendance and/or completion of or failure to apply, attend and/or complete the FVIP and shall be signed by an officer of the agency. OR 5 CIVIL ACTION FILE NO. ____ _________________ _____ Respondent is ordered to undergo a certified family violence intervention program and comply with the attached compliance form. OR _____ Respondent is ordered to undergo a certified family violence intervention program. OR _____ Respondent is not ordered to undergo a certified family violence intervention program and the following reasons exist : ______________________________________________________________________ ________________________________________________________ ___ ___________ _____ 26. Petitioner/protected party is either a spouse, former spouse, parent of a common [pco07 ] child, Petitioner’s child, child of Respondent, cohabitates or has cohabited with Respondent and qualifies for 18 U.S.C. § 922(g ). It is further ordered that the Respondent shall not possess or purchase a firearm or ammunition as restricted by federal law under 18 U.S.C. § 922(g)(8). _____ 27. It is further Ordered : [pco08] _______ ________________ _____________________________ _____________ __________________________________________________________________ ____________________________________ ______________________________ __________________________________________________________________ SO ORDERED this ____ __ _ day of ______________________, 20_____ . __________________________ ___ JUD GE, SUPERIOR COURT _______________ _____ ___ County ___________________________ __ Print or stamp Judge’s name Violation of the above Order may be punishable by arrest. 6 CIVIL ACTION FILE NO. ______ ____________ NOTICE TO RESPONDENT 1. Violation of this Order may result in immediate arrest and criminal prosecution th at may result in jail time and/or fines and/or may subject you to prosecution and penalties for contempt of court. 2. This Order shall remain in effect unless specifically superceded by a subsequent Order signed and filed, by operation of law, or by Order of dismissal, whichever occurs first. Only this Court can void, modify or dismiss this Order. Either party may ask this Court to change or dismiss this Order. 3. If after a hearing, of which the Respondent received notice and opportunity to participate, a pr otective order is issued which restrains Respondent from harassing, stalking or threatening an intimate partner, Respondent is prohibited from possessing, receiving, or transporting a firearm or ammunition which has been shipped or transported in interstat e or foreign commerce for the duration of the Order. 18 U.S.C. § 922(g). 4. A person commits the offense of Aggravated Stalking when such person, in violation of a temporary or permanent protective Order prohibiting this behavior , follows, places under surve illance, or contacts another person on public or private property for the purpose of harassing and intimidating the other person. This activity can subject the Respondent to arrest and prosecution for felony Aggravated Stalking, which carries penalties of imprisonment for not less than 1 year nor more than 10 years and a fine of up to $10,000.00. 7 CIVIL ACTION FILE NO. _____________________ Pursuant to O.C.G.A. § 19 -13 -3, Petitioner assisted by Name: ______________________________ Address: ____________________________ ____________________________________ Telep hone: ______________________ ____ Note to Judges: This form is promulgated as a Uniform Superior Court Rule under the auspices of O.C.G.A. § 19 -13 -53. To order a specific provision, please initial in the space provided. The court should delete or otherwise make inoperative any p rovision in the standardized form which is not supported by the evidence in the case and in order to comply with the court´s application of the law and facts to an individual case. 8 CIVIL ACTION FILE NO. _____________________ *REMOVE THIS PAGE FROM ORDER AND FILE SEPARATELY UNDER SEAL * *F or transmittal to the Georgia Protective Order Registry and, if applicable, the National Crime Information Center .* RESPONDENT’S IDENTIFYING FACT SHEET (please complete as much as possible; one of these must be prov ided to have the order placed in the National Crime Information Center registry: Respondent’s date of birth OR social security number) Respondent’s social security number is _______________, date of birth is _________, sex _ ___, color of hair __________, color of eyes ______________, height _______, weight _____. Respondent’s race is ___ ____ ___, ethnic background ____________. Respondent has distinguishing marks (tattoos, scars, etc.)_____________________. Respondent drives a _____ _____ ____ ____________, l icense tag no: _________ ___ (Expires: __ __) and has a ____(state) driver’s license no: ______ ____ __ _(Expires: ____ ). Respondent’s home address _ _______________ _____________________________ and is employed by____________ __ ____ at ____ ___________ _____________ _____ and works from ____ to ____ on (days)___________. Respondent has the following known aliases: ______ ______________________. PROTECTED PARTIE S’ IDENTIFYING INFORMATION Petitioner: ___________________ ______ DOB __ _____ ___ _ sex _ ______ race ___ _____ ______ Other: _______________________ __ DOB ___ __ ______ sex _______ race ______________ Other: _____________________ ____ DOB _____ __ ____ sex _______ race ______________ Other: ___________________ ______ DOB _______ __ __ sex _______ race ______ ________ Other: _________________________ DOB ___________ sex _______ race ______________  Transmitted to Georgia Protective Order Registry Date _ ___ ______ Clerk ________ ___________________ Rev’ d 8/14 CONFIDENTIAL INFORMATION FORM - ATTENTION COURT STAFF: THIS PAGE IS A RESTRICTED -ACCESS DOCUMENT . This document is not accessible to the public or to other parties.