COCONINO SUPERIOR COURT 200 N SAN FRANCISCO ST FLAGSTAFF AZ 86001 928-779-6535 Case No. Plaintiff/Plaintiff Employer (Work Injunction ONLY) Birth Date: Defendant PETITION for Address Agent’s Name (Work Injunction ONLY) City, State, Zip Code, Phone [ ] Order of Protection [ ] Injunction Against Harassment [ ] Workplace Injunction DIRECTIONS: Please read the Plaintiff’s Guide Sheet before filling out this form. 1. Defendant/Plaintiff Relationship: [ ] Married now or in the past [ ] Live together now or lived together in the past, [ ] Child in common [ ] One of us pregnant by the other [ ] Related (Parent, Inlaw, Brother, Sister or Grandparent) [ ] Dating-never lived together [ ] Other: 2. [ ] If checked, there is a pending action involving maternity, paternity, annulment, legal separation, dissolution, custody, parenting time or support in Superior Court, Case #: (COUNTY) . 3. Have you or the Defendant been charged or arrested for domestic violence OR requested a Protective Order? [ ] Yes [ ] No [ ] Not sure If yes or not sure, explain: 4. I need a Court Order because: (PRINT both the date(s) and briefly what happened): Date(s) Describe what happened (Attach additional paper if necessary – Do not write on back) Page 1 of 2 Effective: January 2007 Adopted by Administrative Directive No. 2006-01 American LegalNet, Inc. www.FormsWorkflow.com 5. The following persons should also be on this Order. As stated in number 4, the Defendant is a danger to them: Name Birthdate 6. Defendant should be ordered to stay away from these locations, at all times, even when I am not present: [] Home: [] Work: [] School/Others: 7. [] If checked, because of the risk of harm, order the defendant NOT to possess firearms or ammunition. 8. [] If checked, request an order for the Defendant to participate in domestic violence counseling or other counseling. 9. Other: Under penalty of perjury, I swear or affirm the above statements are true to the best of my knowledge, and I request an Order / Injunction granting relief as allowed by law. Plaintiff Attest: Judicial Officer/Clerk/Notary Date: Page 2 of 2 Effective: January 2007 Adopted by Administrative Directive No. 2006-01 American LegalNet, Inc. www.FormsWorkflow.com