DISTRICT COURT OF MARYLAND FOR Located at Petitioner (Person seeking protection) Street Address, Apt. No. Home: City, State, Zip Work: Telephone Number(s) City, State, Zip Court Address City/County Case No. vs. Respondent (Person alleged to have committed the prohibited act) Street Address, Apt. No. Home: Work: Telephone Number(s) PETITION FOR PEACE ORDER 1. I (the Petitioner) am seeking protection from the Respondent or over whom I have custody or guardianship Name Name(s) of Children for myself; a minor child of mine ; an adult over whom I have guardianship or Power of Attorney , as a result of the following act(s) committed by the Name Respondent within the last 30 days on the dates stated below. (check all that apply) kicking punching choking slapping shooting rape or other sexual offense (or attempt) hitting with object stabbing shoving threats of violence harassment stalking detaining against will trespass malicious destruction of property misuse of telephone facilities and equipment misuse of electronic communication or interactive computer service revenge porn other visual surveillance The details of what happened are: (Describe injuries. State the date(s) and place(s) where these acts occurred. Be as specific as you can.): 2. I know of the following court cases involving the Respondent and the person(s) for whom I am seeking protection: Court Kind of Case Year Filed Results or Status (if you know) 3. Describe all other harm the Respondent has caused to the person(s) for whom you are seeking protection, and give date(s), if known: 4. I want the Respondent to be ordered: X NOT to commit or threaten to commit any of the acts listed above against Name NOT to contact, attempt to contact, or harass NOT to go to the residence(s) at NOT to go to the school(s) at NOT to go to the work place(s) at To go to counseling. To go to mediation. Other specific relief: Address Name Name of school and address To pay the filing fees and court costs. I solemnly affirm under the penalties of perjury that the contents of this Petition are true to the best of my knowledge, information, and belief. Date Petitioner NOTICE TO PETITIONER Any individual who knowingly provides false information in a Petition for Peace Order is guilty of a misdemeanor and on conviction is subject to a fine not exceeding $1,000 or imprisonment not exceeding 90 days or both. DC-PO-001 (Rev. 10/2016) American LegalNet, Inc. www.FormsWorkFlow.com