Fill and Sign the Sc 22 Form

1 ORI Number ____________________ SC -22 THE SUPERIOR COURT FOR THE COUNTY OF ________________ STATE OF GEORGIA _____________________, : Petitioner, : Civil Action File v. : _____________________, : No. ________________ Respondent. : FAMI LY VIOLENCE THREE YEAR/PERMANENT 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 th e Petitioner requested that the Protective Order entered in this case be converted to a Permanent Family Violence Protective Order. This Court has determined that it had jurisdiction over the subject matter and the parties. Having heard the evidence presen ted, reviewed the Motion and the entire record concerning this case and for good cause shown, IT IS HEREBY ORDERED AND ADJUDGED: 1. That these proceedings be filed in the office of the Clerk of this Court. 2. That this Order applies in every county throu ghout 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 pursuant 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 and the Order issued ______________________, 20_____ shall be permanent pursuant to O.C.G.A. § 19 -13 -4 (c) and have NO expiration date. OR 3.1 This Order shall be in effect for three (3) years and shall expire on ______________________, 20_____ . 4. That the Respondent has violated the Family Violence Act, O.C.G.A. § 19 -13 -1 [pco01] et seq., by committing family viole nce, has placed the Petitioner in reasonable fear for Petitioner’s safety, and 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, harassing, harming, or abusing the Petitioner and/or the minor child/ren in any manner. Respondent is not to interfere with Petitioner’s travel, 2 CIVIL ACTION FILE NO. ____________ _________ transportation, or communication. Respondent shall not follow, place under surveillance, or contact the Petitioner at any place of the Petitioner for the purpose of harassing and intimidating the Petitioner. 5. That the Respondent is enjoi ned and restrained from doing or attempting to do, or [pco 02] threatening to do, any act of injury, maltreating, molesting, harassing, harming, or abusing the Petitioner’s family or household. 6. That this Court determined that it had jurisdiction over t he parties and the subject matter under the laws of the State of Georgia and Respondent 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 sh all 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. Respondent is ordered to stay away from Petitioner’s and Petitioner’s child/ren’s [pco 04] residence and workplace and/or school and any subsequent residence or workplace or school of Petitioner and/or Petitioner’s minor child/ren. _____ 8. That Respondent is restrained and enjoined from approaching within __________ yards [pco01,04] of Petitioner and/or Petitioner’s minor children. _____ 9. Respondent is ordered not to have any contact, direct, indir ect or through another [pco 05] pe rson with Petitioner, by telephone, fax, e -mail or any other means of communication except as specified in this Order. _____ 10. That Petitioner is awarded 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. _____ 11. The _____________ __ shall pay to the _______________ , fo r the support of the minor child/ren, the s um of _________________________________ Dollars ($__________ _) per _____________________ ______ , beginning ______________________, 20_____ . 3 CIVIL ACTION FILE NO. _____________________ All pa yments are t o be made by or to: ____ income deduction order ____ child support receiver ____ by mail directly to the Petitioner or ____ _____________________________. In determining child support the Court finds as follows: The Fathe r’s gross monthly income (before taxes) is $__________ __________ ; The Mother’s gross monthly income (before taxes) is $ __________ __________ . Number of children – The number of children for whom support is being provided under this order is __________ __________ . Deviations: ( ) It has been determined that none of the Deviations allowed under O .C.G.A § 19 -6- 15 applies in this case. OR ( ) It has been determined that one or more of the Deviations allowed under O .C.G.A. § 19 -6-15 applies in this case, as shown by the attached Schedule E . The Presumptive Amount of Child Support that would have been required under O.C.G.A § 19 -6-15 if the deviations had not been applied is $ __________ __________ per month, as shown on the attached Child Support Work sheet . The attached Schedule E explains the reasons for the deviation, how the application of the guidelines would be unjust or inappropriate considering the relative ability of each parent to provide support, and how the best interest of the child/ren wh o is/are subject to this child support determination is served by deviation from the presumptive amount of child support. The Child Support Order Addendum is attached and made a part of this Order. _____ 12. Respondent is ordered to pay temporary support for the Petitioner in the amount of $__________ _ every ______ _____________ beginning ____________ ____________ . All pa yments are to be made by or to: ____ income deduction order ____ child support receiver ____ by mail directly to the Petitioner or ____ _____________________________ . _____ 13. Respondent shall have visitation with the minor child/ren according to the following schedule, beginning ______________________, 20_____ : ____ no visitation ____ no visitation until _____________________________________ ____ supervised visitation, supervised by a third party as follows: ____________________________________________________________ ____________________________________________________________ 4 CIVIL ACTION FILE NO. _____________________ ____ visitation every other weekend from Friday at 6 p.m. until Sunday at 6 p.m beginning ______________________, 20_____ . ____ other visitation _______________________________________________ ____ circumstances concerning how Respondent shall pick up 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. _____ 14. (Resp ondent)(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 remove from the jurisdiction of this Court any of the property or pets of th e Petitioner or joint property or pets of the parties except in the ordinary course of business. _____ 15. (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] is/are ordered not to disconnect or have disconn ected 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. _____ 16. Petitioner is awarded costs and attorney fees in the amount of $ _____________. _____ 17. Petitioner/protected party is either a spouse, former spouse, parent of a common [pco 07] child, Petitioner’s child, child of Respondent, cohabit ates 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). _____ 18. It is f urther Ordered: [pco08] ________________________________________________________________ _____ _ ______________________ ___________________________________________ ____ _ SO ORDERED this _______ day of ______________________, 20_____. _____________________________ JUDGE, SUPERIOR COURT _______________________ County _________________ ____________ Print or stamp Judge’s name Violation of the above Order may be punishable by arrest. 5 CIVIL ACTION FILE NO. _____________________ NOTICE TO RESPONDENT 1. Violation of this Order may result in immediate arrest and criminal prosecution that 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 e ffect unless specifically supers eded by a subsequent Order signed and filed, by operation of law, or by Order of d ismissal, 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 pro tective 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 interstate 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. 6 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 R ule 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 provision in the standardized form which is not supported by the evidence in th e case and in order to comply with the court´s application of the law and facts to an individual case. 7 CIVIL ACTION FILE NO. _____________________ *REMOVE THIS PAGE FROM ORDER AND FILE SEPARATELY UNDER SEAL * *F or transmittal to the Georgia Protectiv e 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 provided to have the order placed in the National Crime Information Center registr y: Respondent’s date of birth OR social security number) Respondent’s social security number is _______________, date of birth is _________, sex ____, color RI KDLU BBBBBBBBBB FRORU RI H\HV BBBBBBBBBBBBBB KHLJKW BBBBBBB ZHLJKW BBBBB  5HVSRQGHQW¶V race is __________, ethnic background ____________. Respondent has distinguishing marks (tattoos, scars, etc.)_____________________. Respondent drives a __________________________, license tag no:____________ (Expires: ____) and has a ____(state) driver’s licens e no: _____________ (Expires: ____). Respondent’s home address _____________________________________________ and is employed by__________________ at _________________________________ and works from ____ to ____ on (days)___________. Respondent has the f ollowing known aliases: ____________________________. PROTECTED PARTIES’ 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.