SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY Downtown Superior Court, 201 W. Jefferson, Phoenix, AZ 85003 Southeast Adult Court, 222 E. Javelina, First Floor, Mesa, AZ 85210 Northeast Regional Court Center, 18380 N. 40th St., Phoenix, AZ 85032 Northwest Regional Court Center, 14264 W. Tierra Buena Lane, Surprise, AZ 85374 Glendale Regional Court Center, 5222 W. Glendale Ave., Glendale, AZ 85301 NCIC# AZ007035J DPS# 0700 Case No. Plaintiff / Plaintiff Employer Name (Work Injunction ONLY) Defendant Name Birth Date: Address Agent’s Name (Work Injunction ONLY) City, State, Zip Code, Phone PETITION for [ ] 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, In-law, 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, (COUNTY) Case #: . 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 describe what happened): Date(s) Describe what happened (Attach additional paper if necessary – Do not write on back) Superior Court of Arizona in Maricopa County Effective: January 2007 DVOP15f Adopted by Administrative Directive No. 2006-01 American LegalNet, Inc. www.FormsWorkFlow.com Case No. 5. The following persons should also be on this Order. As stated in number 4, the Defendant is a danger to them: (___/___/_____) (___/___/_____) Birth Date Birth Date (___/___/_____) (___/___/_____) Birth Date Birth Date 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 Superior Court of Arizona in Maricopa County Effective: January 2007 Attest: Judicial Officer/ Clerk / Notary ___/___/_____ Date DVOP15f Adopted by Administrative Directive No. 2006-01 American LegalNet, Inc. www.FormsWorkFlow.com