Form Adopted for Mandatory Use Judicial Council of California TH-100 [Rev. September 1, 2018] PETITION FOR ORDER PROHIBITING ABUSE OR PROGRAM MISCONDUCT (Transitional Housing Misconduct)Civil Code, 247 1954.13www.courts.ca.gov ATTORNEY OR PARTY WITHOUT ATTORNEYSTATE BAR NUMBER:NAME:FIRM NAME:STREET ADDRESS:CITY:STATE:ZIP CODE:TELEPHONE NO.:FAX NO.:E-MAIL ADDRESS:ATTORNEY FOR (name): SUPERIOR COURT OF CALIFORNIA, COUNTY OFSTREET ADDRESS:MAILING ADDRESS:CITY AND ZIP CODE:BRANCH NAME: PARTICIPANT:PROGRAM OPERATOR: PETITION FOR ORDER PROHIBITING ABUSE OR PROGRAM MISCONDUCT Application for Temporary Restraining Order (date):Modification of Previous Order FOR COURT USE ONLY CASE NUMBER:TH-100(Continued on reverse)operates a "transitional housing program" as defined in Health and Safety Code section 50582(g).(THIS IS NOT AN ORDER)225Read the Instructions for Program Operators before completing this form.225You must have a copy served on the participant at least two days before the hearing.1.Jurisdiction. This suit is filed in this county because participant resides in this county.2.a.b.3. a.b.4.Participant to be restrained or excluded is a "homeless person" dwelling at a "program site" as defined in Civil Code section1954.12 (name all to be restrained or excluded):Age (if under 18) Name Persons living with participant in participant's dwelling unit who are not to be restrained or excluded (name all below). Age (if under 18) Family relationship Name Participant has signed a contract with the program operator. The contract includes (attach a copy of the signed contract)Program rules and regulations.b.A statement of program operator's right of control over and access to the program unit occupied by participant.A summary of the requirements and procedures of Civil Code sections 1954.10-1954.18.Page 1 of 4Program operator (name):Governmental agency (specify):Manager or operatorPrivate nonprofit corporation receiving program funds from a governmental agencyManager or operatorThe funding agency is (specify):Program site (specify street address, city, ZIP Code):Dwelling unit of participant (address optional):Other locations of the program (addresses):If none, check this box: 5.6.a.c. American LegalNet, Inc. TH-100 PARTICIPANT:PROGRAM OPERATOR: CASE NUMBER:(THIS IS NOT AN ORDER) TH-100 [Rev. September 1, 2018] PETITION FOR ORDER PROHIBITING ABUSE OR PROGRAM MISCONDUCT (Transitional Housing Misconduct)Page 2 of 4(Continued on next page)a.b.(1)(2)(3)caused or attempted bodily injurycaused or attempted sexual assaultcaused fear of serious bodily injury(Abuse) has intentionally or recklesslyto program employees, other participants, or persons living within 100 feet of the program site (names and relationships to program):(1)(2)(3)(4)(5)(6)drunkenness on the program site (rule no.):unlawful use or sale of controlled substances (drugs) (rule no.):theft (rule no.):arson (rule no.):destruction of property of the program operator, program employees, other participants, or persons living within 100 feet of the program site (names and relationships to program and rule no.):violence or threats of violence and harassment of program employees, other participants, or persons living within 100 feet of the program site (names and relationships to program and rule no.):c.FACTS. Describe in detail the most recent incidents of program misconduct or abuse. State what happened, the dates andtimes, and who did what to whom. Describe any injuries or damage. For alleged program misconduct, cite the rules andregulations violated by each incident of misconduct. If more space is needed, attach additional pages and check this box:(You may use form MC-031 (on the reverse of form MC-030) as an attachment or for the declarations (affidavits) ofwitnesses.)Participant to be restrained or excluded (names):(Program misconduct) has intentionally violated the program rules and regulations. The violation substantially interferes with the orderly operation of the program AND involves (check at least one and cite the rule number):7. American LegalNet, Inc. TH-100 [Rev. September 1, 2018] PETITION FOR ORDER PROHIBITING ABUSE OR PROGRAM MISCONDUCT (Transitional Housing Misconduct)Page 3 of 4TH-100 PARTICIPANT:PROGRAM OPERATOR: CASE NUMBER:(THIS IS NOT AN ORDER)(Continued on next page)PROGRAM OPERATOR REQUESTS THE COURT TO MAKE THE ORDERS INDICATED BY THE CHECK MARKS IN THE BOXES BELOW.8.a.b.c.d.e.f.drunkenness on the program site (rule no.):unlawful use or sale of controlled substances (drugs) (rule no.):theft (rule no.):arson (rule no.):destruction of property (rule no.):violence or threats of violence and harassment (rule no.):9.a.b.c.program employeesprogram participantspersons living within 100 feet of the program site10.and may take participant's personal property needed until the hearing.11.a.b.Dwelling unit assigned to participant (address optional):Other program site locations (addresses):12.I request that copies of orders be given to the following law enforcement agencies (specify all with jurisdiction over the program sites):Address Law Enforcement Agency 14.PROGRAM MISCONDUCT RESTRAINING ORDERS (BREAKING RULES). Participant must not intentionally violate the program rules and regulations so as to interfere substantially with the orderly operation of the program and specifically the rules and regulations onABUSE RESTRAINING ORDERS. Participant must not attack, strike, batter, or sexually assault, or threaten to attack, strike, batter, or sexually assaultPROGRAM SITE EXCLUSION ORDERS. Participant must immediately move from and must not return to the program site and the dwelling unit assigned to participant (address optional):STAY-AWAY ORDERS.Participant must stay at least 200 feet away from the following places:OTHER ORDERS (specify other orders you request to help carry out the orders requested in items 8-11):PREVIOUS PETITIONS. I have asked for restraining orders against participant before (specify case numbers and dates):13. and specifically the following persons (names): American LegalNet, Inc. TH-100 [Rev. September 1, 2018] PETITION FOR ORDER PROHIBITING ABUSE OR PROGRAM MISCONDUCT (Transitional Housing Misconduct)Page 4 of 4TH-100 PARTICIPANT:PROGRAM OPERATOR: CASE NUMBER:(THIS IS NOT AN ORDER) (1)(2)(i)(ii)a restraining order is in effect and subject to further orders (specify in item 14).an action is pending against participant (specify in item 14).b.Notice to participant.of the date, time, and place this petition would be filed.(1)(2)(3)a.Participantc.has not been under contract with the program for more than six months (date of contract):has been under contract with the program for more than six months, butProgram operatorOperator's attorney (attach attorney's affidavit)informed participant or his or her attorney on (date):at (time):made the following good-faith efforts to inform participant or his or her attorney of the date, time, and place this petition would be filed (specify efforts):should not be required to inform the participant or his or her attorney of the date, time, and place this petition would be filed because (specify reasons):NEED FOR IMMEDIATE ORDER BEFORE THE HEARING. Program operator, program participants, or persons living within 100 feet of the program site will suffer great and irreparable harm before this petition can be heard in court unless the court makes those orders requested above effective now and until the hearing. (Specify the harm and why it will occur before the hearing. For temporary exclusion orders under items 10-11, show emergency and need to prevent imminent serious bodily injury.)15.16.I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. (SIGNATURE OF PROGRAM OPERATOR)REQUEST FOR TEMPORARY RESTRAINING ORDER To Be Effective From Now Until the HearingI request that the orders requested in items be effective from now until the hearing. (Note: Temporary exclusion orders under items 10-11 require an emergency.)89101112 Number of pages attached:Date: (TYPE OR PRINT NAME)TITLE of person signing: American LegalNet, Inc.