DV-100 Request for Domestic Violence Restraining Order Clerk stamps date here when form is filed. You must also complete Form CLETS-001, Confidential CLETS Information, and give it to the clerk when you file this Request. 1 Name of Person Asking for Protection: Age: Your lawyer in this case (if you have one): Name: State Bar No.: Firm Name: Address (If you have a lawyer for this case, give your lawyer's information. If you do not have a lawyer and want to keep your home address private, give a different mailing address instead. You do not have to give your telephone, fax, or e-mail.): Address: City: State: Zip: Fax: Telephone: E-Mail Address: Fill in court name and street address: Superior Court of California, County of Court fills in case number when form is filed. 2 Name of Person You Want Protection From: Description of person you want protection from: Sex: M F Height: Race: Address (if known): City: Weight: Case Number: Hair Color: Eye Color: Date of Birth: Age: State: Zip: Yes No 3 Do you want an order to protect family or household members? If yes, list them: Full name Sex Age Relationship to you Lives with you? Yes No Yes No Yes No Check here if you need more space. Attach a sheet of paper and write "DV-100, Protected People" for a title. We are now married or registered domestic partners. If you do not have one of these relationships, We used to be married or registered domestic partners. the court may not be able to consider your We live together. request. Read Form DV-500-INFO for help. We used to live together. We are related by blood, marriage, or adoption (specify relationship): We are dating or used to date, or we are or used to be engaged to be married. We are the parents together of a child or children under 18: Child's Name: Date of Birth: Child's Name: Date of Birth: Child's Name: Date of Birth: Check here if you need more space. Attach a sheet of paper and write "DV-100, Additional Children" for a title. We have signed a Voluntary Declaration of Paternity for our child or children. (Attach a copy if you have one). 4 What is your relationship to the person in 2 ? (Check all that apply): a. b. c. d. e. f. g. h. This is not a Court Order. Judicial Council of California, www.courts.ca.gov Revised July 1, 2016, Mandatory Form Family Code, § 6200 et seq. Request for Domestic Violence Restraining Order (Domestic Violence Prevention) DV-100, Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: 5 Other Restraining Orders and Court Cases a. Are there any restraining/protective orders currently in place OR that have expired in the last six months (emergency protective orders, criminal, juvenile, family)? and (expiration date): (Attach a copy if you have one). No Yes (date of order): b. Have you or any other person named in 3 been involved in another court case with the person in 2 ? No Yes If yes, check each kind of case and indicate where and when each was filed: Case Number (if known) County or Tribe Where Filed Year Filed Kind of Case Divorce, Nullity, Legal Separation Civil Harassment Domestic Violence Criminal Juvenile, Dependency, Guardianship Child Support Parentage, Paternity Other (specify): Check here if you need more space. Attach a sheet of paper and write "DV-100, Other Court Cases" for a title. Check the orders you want. 6 Personal Conduct Orders I ask the court to order the person in 2 not to do the following things to me or anyone listed in 3 : a. Harass, attack, strike, threaten, assault (sexually or otherwise), hit, follow, stalk, molest, destroy personal property, disturb the peace, keep under surveillance, impersonate (on the Internet, electronically or otherwise), or block movements Contact, either directly or indirectly, in any way, including but not limited to, by telephone, mail or e-mail b. or other electronic means The person in 2 will be ordered not to take any action to get the addresses or locations of any protected person unless the court finds good cause not to make the order. 7 Stay-Away Order a. I ask the court to order the person in 2 to stay at least yards away from (check all that apply): Me My school My home Each person listed in 3 My job or workplace The child(ren)'s school or child care My vehicle Other (specify): b. If the person listed in 2 is ordered to stay away from all the places listed above, will he or she still be able to Yes No (If no, explain): get to his or her home, school, job, workplace, or vehicle? 8 Move-Out Order (If the person in 2 lives with you and you want that person to stay away from your home, you must ask for this move-out order.) I ask the court to order the person in 2 to move out from and not return to (address): I have the right to live at the above address because (explain): This is not a Court Order. Revised July 1, 2016 Request for Domestic Violence Restraining Order (Domestic Violence Prevention) DV-100, Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: 9 Guns or Other Firearms or Ammunition I believe the person in 2 owns or possesses guns, firearms, or ammunition. Yes No I don't know If the judge approves the order, the person in 2 will be ordered not to own, possess, purchase, or receive a firearm or ammunition. The person will be ordered to sell to, or store with, a licensed gun dealer, or turn in to law enforcement, any guns or firearms that he or she owns or possesses. 10 11 Record Unlawful Communications I ask for the right to record communications made to me by the person in 2 that violate the judge's orders. Care of Animals I ask for the sole possession, care, and control of the animals listed below. I ask the court to order the person in 2 to stay at least yards away from and not take, sell, transfer, encumber, conceal, molest, attack, strike, threaten, harm, or otherwise dispose of the following animals: I ask for the animals to be with me because: 12 Child Custody and Visitation I do not have a child custody or visitation order and I want one. a. b. I have a child custody or visitation order and I want it changed. If you ask for orders, you must fill out and attach Form DV-105, Request for Child Custody and Visitation Orders. You and the other parent may tell the court that you want to be legal parents of the children (use Form DV-180, Agreement and Judgment of Parentage). Child Support (Check all that apply): I do not have a child support order and I want one. a. I have a child support order and I want it changed. b. I now receive or have applied