CH-100 1 Request for Orders to Stop Harassment Clerk stamps date here when form is filed. 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): Fill in court name and street address: Superior Court of California, County of 2 Name of person you want protection from: Describe the person: Sex: Height: Eye Color: M Race: Age: Court fills in case number when form is filed. F Weight: Hair Color: Date of Birth: Case Number: Home Address (if you know): 3 Zip: City: State: Work Address (if you know): Zip: City: State: Besides you, who needs protection? (Family or household members) Lives with you? How are they related to you? Age Sex Full Name Yes No Yes No Yes No Yes No Check here if you need more space. Attach a sheet of paper and write “CH-100, item 3—Describe Protected Persons” at the top of the page. 4 5 Why are you filing in this court? (Check all that apply): The person in 2 lives in this county. I was hurt (physically or emotionally) by the person in Other (specify): How do you know the person in 2 2 here. ? (Describe): This is not a Court Order. Judicial Council of California, www.courtinfo.ca.gov Revised July 1, 2007, Mandatory Form Code of Civil Procedure, §§ 527.6 and 527.9 Request for Orders to Stop Harassment CH-100, Page 1 of 4 (Civil Harassment) American LegalNet, Inc. www.FormsWorkflow.com Case Number: Your name: 6 Describe how the person in 2 has harassed you: a. Date of most recent harassment: b. Who was there? c. Did the person in 2 commit any acts of violence or threaten to commit any acts of violence against you? Yes No If yes, describe those acts or threats: d. Did the person in Yes distress? If yes, describe: 2 engage in a course of conduct that harassed you and caused substantial emotional No e. Did the conduct of the person in 2 described above seriously alarm, annoy, or harass you? Check here if you need more space. Attach a sheet of paper and write “CH-100, item 6 Harassment” at the top of the page. Yes No Describe Check the orders you want 7 Personal Conduct Orders I ask the court to order the person in 2 to not do the following things to me or anyone listed in 3 : a. Harass, attack, strike, threaten, assault (sexually or otherwise), hit, follow, stalk, destroy personal property, 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 also be ordered not to take any action to get the addresses or locations of any protected persons, their family members, or their caretakers unless the court finds good cause not to make the order. 8 Stay-Away Orders I ask the court to order the person in 2 to stay at least (specify): yards away from me and the people listed in 3 and the places listed below: (Check all that apply): My home My vehicle a. d. My job or workplace b. e. Other (specify): c. My children’s school or child care If the court orders the person in 2 to stay away from all the places listed above, will that person Yes still be able to get to his or her home, school, or job? No If no, explain: This is not a Court Order. Revised July 1, 2007 Request for Orders to Stop Harassment (Civil Harassment) CH-100, Page 2 of 4 Case Number: Your name: 9 10 Others to Be Protected Should the other people listed in 3 also be covered by the orders described above? Yes Does not apply No If yes, explain: Order About Guns or Other Firearms I ask the court to order the person in 2 to be prohibited from owning, possessing, purchasing, or receiving, or attempting to purchase or receive firearms and to sell or turn in any guns or firearms that he or she controls. 11 12 Other Orders I ask the court to order the person in 2 to (specify): Temporary Orders Do you want the court to make orders now on the matters listed in hearing? Yes No If yes, explain why you need these orders right now: 7 , through 11 that will last until the Check here if you need more space. Attach a sheet of paper and write “CH-100, item 12—Temporary Orders” at the top of the page. 13 Delivery of Orders to Law Enforcement My lawyer or I will give copies of the orders to the following law enforcement agencies: a. Name of Agency: Address: City: State: Zip: State: Zip: b. Name of Agency: Address: City: 14 Other Court Cases Have you ever asked any court for other restraining orders against the person in If yes, specify the counties and case numbers if you know them: 2 ? Yes No This is not a Court Order. Revised July 1, 2007 Request for Orders to Stop Harassment (Civil Harassment) CH-100, Page 3 of 4 Case Number: Your name: 15 Time for Service You must have your papers personally served on (notify) the person in 2 at least 5 days before the hearing, unless the court orders a different time for service. (Form CH-135 explains “What Is Proof of Service?” Form CH-130 may be used to show the court that the papers have been served.) If your papers cannot be served at least 5 days before the hearing and you need more time, explain why: 16 No Fee for Filing I ask the court to waive the filing fee because the person in 2 has used or threatened to use violence against me, has stalked me, or has acted or spoken in some other way that makes me reasonably fear violence. I am asking for a restraining order to stop this conduct. 17 No Fee to Serve Orders I ask the court to order the sheriff or marshal to serve (notify) the person in 2 about the orders for free because: a. My request for orders is based on stalking; or b. My request for orders is based on a credible threat of violence; or c. I am entitled to a fee waiver. (If you are requesting free service of the orders based on a fee waiver, you must complete and file the Application for Waiver of Court Fees and Costs (Form FW-001).) 18 Lawyer’s Fees and Costs I ask the court to order payment of my: Lawyer’s fees a. Out-of-pocket expenses b. The amounts requested are: Item Amount $ Item Amount $ $ $ $ $ Check here if you need more space. Attach a sheet of paper and write “CH-100, item 18—Lawyer’s Fees and Costs” at the top of the page. 19 Additional Relief I ask the court for additional relief as may be proper. 20 Number of pages attached to this form, if any: Date: Lawyer’s name Lawyer’s signature I declare under penalty of perjury under the laws of the State of California that the information above and on all attachments is true and correct. Date: Type or print your name Sign your name This is not a Court Order. Revised July 1, 2007 Request for Orders to Stop Harassment (Civil Harassment) CH-100, Page 4 of 4