EA-100 1 Request for Orders to Stop Elder or Dependent Adult Abuse Clerk stamps date here when form is filed. Name of the person asking for protection: Address of the person (skip this if you have a lawyer): (If you want your address to be private, give a mailing address instead): City: State: Zip: Person’s telephone number (optional): ( _____ ) _______________________ Person’s 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 the person you want protection from: Describe the person: Sex: Height: Eye color: M F Weight: Court fills in case number when form is filed. Case Number: Hair color: Date of birth: Race: Age: Home address (if you know): State: 3 Zip: State: City: Work address (if you know): City: Zip: Who is asking the court for protection? You, to protect yourself. A person acting on your behalf: Another person with legal authority to represent you. A conservator If you are requesting protection for yourself, indicate that and go on to 4 . If someone else is making this request, that person must attach a statement of who he or she is, his or her legal authority to make this request, and information about this representation, including any court appointments, the case numbers, and other relevant matters. Attach a sheet of paper and write “EA-100, item 3—Information About Person Requesting Orders.” 4 Describe the person asking for protection: a. Age: b. If you are under age 65, do you have any physical or mental limitations that prevent you from carrying out normal activities or protecting your rights? Yes No (If yes, describe): Check here if you need more space. Attach a sheet of paper and write “EA-100, item 4—Describe Protected Person” at the top of the page. This is not a Court Order. Judicial Council of California, www.courtinfo.ca.gov Revised July 1, 2008, Mandatory Form Welfare & Institutions Code, § 15657.03 Request for Orders to Stop Elder or Dependent Adult Abuse EA-100, Page 1 of 6 (Elder or Dependent Adult Abuse Prevention) American LegalNet, Inc. www.FormsWorkflow.com Case Number: Your name: 5 How do you know the person in 6 Why are you filing in this court? (Check all that apply): I was abused physically or emotionally in this county by the person in The person in 2 lives in this county. Other (explain): 7 a. Have you and the person in 2 2 ? (Describe): 2 been involved in another court case? If yes, where? County: What is the case number? (If you know): What kind of case? (Check all that apply): Dependent adult abuse Elder abuse Domestic violence Criminal Other (specify): . Yes No State: Civil harassment b. Are there now any protective or restraining orders relating to you and the person in 2 ? If yes, attach a copy if you have one. No Yes Check here if you need more space. Attach a sheet of paper and write “EA-100, item 7—Describe Other Cases” at the top of the page. 8 No Yes Is this your first request for a protective order against the person in 2 ? No Yes If no, are you asking for the renewal of an earlier protective order? If you are asking for the renewal of an earlier order, provide the following information: a. What was the case number of the earlier order? permanently _______ years b. How long do you want the renewed order to last? 9 Describe in a. through i. how the person in 2 has abused you. a. When was the most recent abuse (provide date or estimated date): b. Who was there? This is not a Court Order. Revised July 1, 2008 Request for Orders to Stop Elder or Dependent Adult Abuse (Elder or Dependent Adult Abuse Prevention) EA-100, Page 2 of 6 Case Number: Your name: c. In the most recent abuse, did the person in 2 do any of the following to you: physically abuse, financially abuse, intimidate, molest, attack, assault (sexually or otherwise), hit, follow, stalk, threaten, harass, destroy personal property, keep under surveillance, block movements, or contact you (directly or indirectly) by telephone, mail, e-mail, messenger, or by any other means? Yes No If yes, describe: d. Has the person in If yes, describe: 2 previously abused you? Yes No e. Describe any use or threatened use of guns or other weapons: f. Did the police come? No Yes If yes, did they give you an Emergency Protective Order? Attach a copy, if you have one. Yes No I don’t know g. Is the person in 2 a caregiver who didn’t allow you to have goods or services you needed to avoid physical harm or mental suffering? Yes No If yes, describe how that affected you: This is not a Court Order. Revised July 1, 2008 Request for Orders to Stop Elder or Dependent Adult Abuse (Elder or Dependent Adult Abuse Prevention) EA-100, Page 3 of 6 Case Number: Your name: h. Did the case involve solely financial abuse unaccompanied by force, threat, harassment, intimidation, or any other form of abuse? Yes, only financial abuse. No, included other abuse described above. i. Describe any injuries or harm you suffered as a result of the actions or deprivation described above: Check here if you need more space to explain any of the subparts in item 9. Attach a sheet of paper and write “EA-100, item 9, subpart ___—Describe Abuse” at the top of the page. Check the orders you want 10 Personal Conduct Orders I ask the court to order the person in 2 to not do the following things to me: a. Physically abuse, financially abuse, intimidate, molest, attack, assault (sexually or otherwise), hit, follow, stalk, threaten, harass, destroy my personal property, keep me under surveillance, or block my movements. Contact (either directly or indirectly), or telephone, or send messages or mail or e-mail. b. The person in 2 will be ordered not to take any action to get the addresses or locations of any protected person, or of that person’s family members or caretakers, unless the court finds good cause not to make the order. 11 Stay-Away Orders I ask the court to order the person in 2 to stay at least (specify): and the places listed below (Check all that apply): My home a. My job or workplace b. c. My vehicle d. Other (specify): If the court orders the person in to get to his or her home or job? If no, explain: 12 2 yards away from me to stay away from all the places checked above, will that person be able Yes No Move-Out Order I ask the court to order the person in 2 to move out from and not return to my residence at (address): I will suffer physical or emotional harm if the person in 2 does not leave the residence. The title or lease to the residence is not in the sole name of the person in 2 and another person. 2 or the name of the person in This is not a Court Order. Revised July 1, 2008 Request for Orders to Stop Elder or Dependent Adult Abuse (Elder or Dependent Adult Abuse Prevention) EA-100, Page 4 of 6 Case Number: Your name: Check the orders you want (continued) I ask for this move-out order right away to last until the hearing, because: a. I have the right to live at the above residence (explain): b. The person in 13 2 assaulted or threatened me. 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. The abuse in this case is not solely financial abuse unaccompanied by force, threat, harassment, intimidation, or any other form of abuse. 14 15 Other Orders What other orders are you asking for? (Describe): Check here if you need more space. Attach a sheet of paper and write “EA-100, item 14—Other Orders” at the top of the page. Temporary Orders Do you want the court to make orders right now on matters listed in 10 through 14 ? Yes No If yes, explain why: 16 Check here if you need more space. Attach a sheet of paper and write “EA-100, item 15 Orders” at the top of the page. Delivery of Orders to Law Enforcement Agencies I request that copies of the court’s orders be given by (check one): The court clerk Myself Temporary My lawyer to the following law enforcement agencies: a. Name of Agency: Address: City: State: Zip: State: Zip: b. Name of Agency: Address: City: This is not a Court Order. Revised July 1, 2008 Request for Orders to Stop Elder or Dependent Adult Abuse (Elder or Dependent Adult Abuse Prevention) EA-100, Page 5 of 6 Case Number: Your name: 17 18 19 Request to Shorten Time for Service You must have your papers personally served on the person in 2 at least 5 days before the hearing, unless the court orders a different time for service. (Form EA-142-INFO, “What is Proof of Service?,” explains how to serve (notify) the person in 2 . Form EA-140 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: No Fee to Serve Orders If you want the sheriff or marshal to serve (notify) the person in clerk what you need to do. Lawyer's Fees and Costs I ask the court to order payment of my: Lawyer’s fees a. Court costs b. The amounts requested are: Item Amount $ $ 2 about the orders for free, ask the court Amount Item $ $ $ $ Check here if you need more space. Attach a sheet of paper and write “EA-100, item 19 Costs” at the top of the page. 20 21 Lawyer’s Fees and Additional Relief I ask the court for additional relief as may be proper. Number of pages attached to this form, if any: This Request for Orders to Stop Abuse must be personally served on the person in orders may not serve these papers. 2 . The person requesting the 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 is true and correct. Date: Name of person filing this request Signature of person filing this request This is not a Court Order. Revised July 1, 2008 Request for Orders to Stop Elder or Dependent Adult Abuse (Elder or Dependent Adult Abuse Prevention) EA-100, Page 6 of 6