DV-100 1 Clerk stamps date here when form is filed. Request for Order Your name (person asking for protection): Your address (skip this if you have a lawyer): (If you want your address to be private, give a mailing address instead): City: State: Zip: Your telephone number (optional): Your lawyer (if you have one): (Name, address, telephone number, and State Bar number): 2 4 Superior Court of California, County of Name of person you want protection from: Clerk fills in case number when form is filed. Description of that person: Sex: Weight: Race: Age: Eye Color: 3 Fill in court name and street address: M F Height: Hair Color: Date of Birth: Case Number: Besides you, who needs protection? (Family or household members): Age Full Name Lives with you? Yes No Yes No Yes No No Yes How are they related to you? Check here if you need more space. Attach Form MC-020 and write “DV-100, Item 3—Protected People” by your statement. NOTE: In any item that asks for Form MC-020, you can use an 8 1/2 x 11-inch sheet of paper instead. What is your relationship to the person in 2 ? (Check all that apply): a. We are now married or registered domestic partners. b. We used to be married or registered domestic partners. c. We live together. d. We used to live together. e. We are relatives, in-laws, or related by adoption (specify relationship): f. We are dating or used to date. g. We are engaged to be married or were engaged to be married. h. 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 Form MC-020 and write “DV-100, Item 4h” by your statement. i. We have signed a Voluntary Declaration of Paternity for our child or children. (Attach a copy if you have one.) This is not a Court Order. Judicial Council of California, www.courtinfo.ca.gov Revised July 1, 2009, Mandatory Form Family Code, § 6200 et seq. Request for Order DV-100, Page 1 of 4 (Domestic Violence Prevention) American LegalNet, Inc. www.FormsWorkflow.com Case Number: Your name: 5 Other Court Cases a. Have you and the person in 2 been involved in another court case? No Yes If yes, where? County: State: What are the case numbers? (If you know): What kind of case? (Check all that apply): Registered Domestic Partnership Divorce/Dissolution Parentage/Paternity Domestic Violence Criminal Juvenile Child Support Nullity Other (specify): Legal Separation Civil Harassment b. Are there any domestic violence restraining/protective orders now (criminal, juvenile, family)? No Yes If yes, attach a copy if you have one. What orders do you want? Check the boxes that apply to your case. 6 Personal Conduct Orders I ask the court to order the person in 2 not to do the following things to me or any of the people listed in 3 : Harass, attack, strike, threaten, assault (sexually or otherwise), hit, follow, stalk, molest, destroy a. personal property, disturb the peace, keep under surveillance, or block movements Contact (either directly or indirectly), or telephone, or send messages or mail or e-mail b. The person in 2 will be ordered not to take any action to get the addresses or locations of any protected person, their family members, caretakers, or guardians unless the court finds good cause not to make the order. 7 Stay-Away Order yards away from (check all that apply): I ask the court to order the person in 2 to stay at least e. The children’s school or child care a. Me My vehicle b. The people listed in 3 f. c. g. Other (specify): My home d. My job or workplace If the person listed in 2 is ordered to stay away from all the places listed above, will he or she still be able No (If no, explain): Yes to get to his or her home, school, job, or place of worship? 8 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): 9 Child Custody, Visitation, and Child Support I ask the court to order child custody, visitation, and/or child support. You must fill out and attach Form DV-105. 10 Spousal Support You can make this request only if you are married to, or are a registered domestic partner of, the person in 2 and no spousal support order exists. To ask for spousal support, you must fill out, file, and serve Form FL-150 before your hearing. This is not a Court Order. Revised July 1, 2009 Request for Order (Domestic Violence Prevention) DV-100, Page 2 of 4 Case Number: Your name: 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. 12 Property Control I ask the court to give only me temporary use, possession, and control of the property listed here: 13 Animals: Possession and Stay-Away Order 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: 14 Debt Payment I ask the court to order the person in 2 to make these payments while the order is in effect: Check here if you need more space. Attach Form MC-020 and write “DV-100, Item 14—Debt Payment” by your statement. Pay to: For: Due date: Amount: $ Due date: Pay to: For: Amount: $ 15 Property Restraint I am married to or have a registered domestic partnership with the person in 2 . I ask the judge to order that the person in 2 not borrow against, sell, hide, or get rid of or destroy any possessions or property, except in the usual course of business or for necessities of life. I also ask the judge to order the person in 2 to notify me of any new or big expenses and to explain them to the court. 16 Attorney Fees and Costs I ask that the person in 2 pay some or all of my attorney fees and costs. You must complete and file Form FL-150, Income and Expense Declaration. 17 Payments for Costs and Services I ask that the person in 2 pay the following: You can ask for lost earnings or your costs for services caused directly by the person in 2 (damaged property, medical care, counseling, temporary housing, etc.). You must bring proof of these expenses to your hearing. Pay to: For: Amount: $ Pay to: For: Amount: $ 18 Batterer Intervention Program I ask the court to order the person listed in 2 to go to a 52-week batterer intervention program and show proof of completion to the court. 19 No Fee to Serve (Notify) Restrained Person If you want the sheriff or marshal to serve (notify) the restrained person about the orders for free, ask the court clerk what you need to do. This is not a Court Order. Revised July 1, 2009 Request for Order (Domestic Violence Prevention) DV-100, Page 3 of 4 Case Number: Your name: 20 More Time for Notice I need extra time to notify the person in 2 about these papers. Because of the facts explained on this form, I days before the date of the hearing. For help, read Form DV-210-INFO. want the papers served up to If necessary, add additional facts: 21 Other Orders What other orders are you asking for? Check here if you need more space. Attach Form MC-020 and write “DV-100, Item 21—Other Orders” by your statement. 22 Guns or Other Firearms I believe the person in 2 owns or possesses guns or firearms. Yes No I don’t know If the judge approves the order, the person in 2 will be required to sell to a gun dealer or turn in to police any guns or firearms that he or she owns or possesses. 23 Describe the most recent abuse. a. Date of most recent abuse: b. Who was there? c. What did the person in 2 do or say that made you afraid? d. Describe any use or threatened use of guns or other weapons: e. Describe any injuries: f. Did the police come? No Yes If yes, did they give you an Emergency Protective Order? Yes No I don’t know Attach a copy if you have one. Check here if you need more space. Use Form MC-020 and write “DV-100, Item 23—Recent Abuse” by your statement. Check here if the person in 2 has abused you (or your children) other times. Use Form DV-101 or Form MC-020 to describe any previous abuse. I declare under penalty of perjury under the laws of the State of California that the information above is true and correct. Date: Type or print your name Sign your name This is not a Court Order. Revised July 1, 2009 Request for Order (Domestic Violence Prevention) DV-100, Page 4 of 4