All Courts in Arizona/NCIC#/DPS# Address City, Arizona Zip Code Telephone Number Case No. Plaintiff / Plaintiff Employer (Work Injunction ONLY) Birth Date: Defendant PETITION for [ ] Order of Protection [ ] Injunction Against Harassment [ ] Workplace Injunction Address Agent’s Name (Work Injunction ONLY) City, State, Zip Code, Phone 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) [ ] Romantic or sexual relationship (current or previous) [ ] Dating but not a romantic or sexual relationship [ ] 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 what happened): Date(s) Describe what happened (Attach additional paper if necessary – Do not write on back) Effective: September 30, 2009 Page 1 of 2 Adopted by Administrative Directive No. 2009-26 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. Attest: Judicial Officer/ Clerk / Notary Plaintiff Effective: September 30, 2009 Page 2 of 2 ___/___/_____ Date Adopted by Administrative Directive No. 2009-26 American LegalNet, Inc. www.FormsWorkFlow.com