WV-100 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: FOR COURT USE ONLY FAX NO. (Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PLAINTIFF: DEFENDANT: EMPLOYEE: PETITION OF EMPLOYER FOR INJUNCTION PROHIBITING VIOLENCE OR THREATS OF VIOLENCE AGAINST EMPLOYEE AND APPLICATION FOR TEMPORARY RESTRAINING ORDER CASE NUMBER: Read the Instructions for Petitions to Prohibit Workplace Violence (form WV-150) before completing this form. NOTE: Plaintiff must be an employer with standing to bring this action under Code of Civil Procedure section 527.8. 1. Plaintiff (name): other (specify): is a corporation sole proprietorship and is filing this suit on behalf of the employee identified in item 2. 2. Employee (name): Sex: M (Use a separate petition for each employee you are seeking to protect. Identify related actions in item 5.) F Date of birth: 3. Defendant (name): Sex: M F Ht.: Wt.: Hair color: Eye color: Race: Age: Date of birth: a. Resides at (address, if known): b. Works at (address, if known): c. Is Is not a current employee of plaintiff (explain if defendant is still an employee): 4. This suit is filed in this county because a. defendant resides in this county. defendant has caused physical or emotional injury to plaintiff's employee in this county. b. other (specify): c. 5. Related Actions a. Plaintiff has asked, or is asking, for restraining orders against the defendant in (specify): case no. (specify): County, b. Employee has asked, or is asking, for restraining orders against defendant in (specify): case no. (specify): County, c. Other related actions (describe): (This not a Court Order.) This is is not a CourtOrder. Form Adopted for Mandatory Use Judicial Council of California WV-100 [Rev. January 1, 2007] PETITION OF EMPLOYER FOR INJUNCTION PROHIBITING VIOLENCE OR THREATS OF VIOLENCE AGAINST EMPLOYEE (Workplace Violence) Page 1 of 4 Code of Civil Procedure, §§ 527.8 and 527.9 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkflow.com WV-100 CASE NUMBER: PLAINTIFF (Name): DEFENDANT (Name): EMPLOYEE (Name): 6. Defendant has assaulted battered stalked made a credible threat of violence against the employee by knowing or willing statements or a course of conduct that would place a reasonable person in fear for his or her safety, or the safety of his or her immediate family. a. One or more of these acts can reasonably be construed to be carried out or to have been carried out at the employee's workplace at (address): b. Describe what happened (including the dates, who did what to whom, and any injuries): Continued on Attachment 6b. 7. Employee will suffer great and irreparable harm before this petition can be heard in court unless the court makes those orders requested below effective now and until the hearing. (Specify the harm and why it will occur before the hearing): Continued on Attachment 7. 8. Defendant's conduct has been directed against employee and is knowing and willful, is not constitutionally protected, and does not constitute lawful acts of self-defense or defense of others. PLAINTIFF REQUESTS THE COURT TO MAKE THE ORDERS INDICATED BY THE CHECK MARKS IN THE BOXES BELOW. 9. PERSONAL CONDUCT ORDERS To be ordered now and effective until the hearing a. Defendant shall not engage in unlawful violence or make threats of violence against the employee and the following members of employee's family or household who reside with the employee: (1) (Name): Sex: M F Date of birth: M F Date of birth: M F Date of birth: (2) (Name): Sex: (3) (Name): Sex: Continued on Attachment 9a. b. Specifically, defendant (1) shall not assault, batter, or stalk the employee and other protected persons. shall not follow or stalk the employee and other protected persons to or from the place of work. (2) (3) shall not follow the employee and other protected persons during hours of employment. (4) shall not telephone or send correspondence to the employee and other protected persons by any means including, but not limited to, the use of the public or private mails, interoffice mail, fax, or e-mail. (5) shall not enter the workplace of the employee and other protected persons. (6) other (specify): The court shall order that the defendant is prohibited from taking any action to obtain the address or location of the employee, or of any of the employee's family members or caretakers, unless the court finds that there is good cause not to make that order. (This is not a Court Order.) WV-100 [Rev. January 1, 2007] PETITION OF EMPLOYER FOR INJUNCTION PROHIBITING VIOLENCE OR THREATS OF VIOLENCE AGAINST EMPLOYEE (Workplace Violence) Page 2 of 4 WV-100 CASE NUMBER: PLAINTIFF (Name): DEFENDANT (Name): EMPLOYEE (Name): 10. To be ordered now and effective until the hearing STAY-AWAY ORDERS a. Defendant shall stay at least (specify): yards away from the following places and persons (the addresses of the places are optional and may be kept confidential): and other protected persons identified in item 9a. (1) Employee (2) Residence of employee and other protected persons (address optional): (3) Place of work of employee and other protected persons (address optional): (4) School or place of child care of children of employee or other protected persons (address optional): (5) Vehicle of employee or other protected persons (specify): (6) Other (specify): b. Will granting of any of the stay-away orders in item 10a deprive defendant of access to his or her residence or place of employment? Yes 11. No (If yes, explain): FIREARMS PROHIBITION AND RELINQUISHMENT ORDER Plaintiff requests an order under section 527.9 of the Code of Civil Procedure that the restrained person is prohibited from owning, possessing, purchasing, or receiving, or attempting to purchase or receive a firearm, and must relinquish any firearm that he or she owns or possesses. 12. OTHER ORDERS (specify other orders you request to help carry out the orders previously requested): 13. DELIVERY TO LAW ENFORCEMENT Plaintiff requests that copies of orders be given to the following law enforcement agencies: Address Law enforcement agency 14. TIME FOR SERVICE Plaintiff requests that time for service of the Order to Show Cause and Temporary Restraining Order (CLETS) (form WV-120) and accompanying papers be no less than (check one): 5 days (specify number): days before the date set for the hearing. (If you need an order shortening the time to fewer than 5 days, explain the reasons): (This is not a Court Order.) WV-100 [Rev. January 1, 2007] PETITION OF EMPLOYER FOR INJUNCTION PROHIBITING VIOLENCE OR THREATS OF VIOLENCE AGAINST EMPLOYEE (Workplace Violence) Page 3 of 4 WV-100 CASE NUMBER: PLAINTIFF (Name): DEFENDANT (Name): EMPLOYEE (Name): 15. COSTS Defendant should be ordered to pay costs as follows (specify): 16. Plaintiff requests additional relief as may be proper. 17. NO FEE FOR FILING Plaintiff is not required to pay a fee for filing this petition because the petition alleges that the defendant has inflicted or threatened violence against an employee of the plaintiff, or stalked the employee, or acted or spoke in any other manner that has placed the employee in reasonable fear of violence, and seeks protective or restraining orders or injunctions restraining stalking or future violence or threats of violence in an action brought under Code of Civil Procedure § 527.8. 18. Plaintiff understands that if the court issues an Order to Show Cause (form WV-120), a hearing will be held on the date shown in item 2 of the Order to Show Cause. At that hearing, plaintiff will be prepared to present evidence supporting the petition. 19. Number of pages attached: (TYPE OR PRINT NAME OF ATTORNEY) (SIGNATURE OF ATTORNEY) I declare under penalty of perjury under the laws of the State of California that I am aware of the facts stated, a. on the basis of my own personal knowledge. on the basis that I have been informed and believe that the facts stated are true. (NOTE: If this petition is made solely on b. the basis of plaintiff's information and belief, plaintiff must attach declarations by one or more persons who have personal knowledge of the facts stated.) Date: (TYPE OR PRINT NAME) (SIGNATURE OF PLAINTIFF) Title of person signing: (This is not a Court Order.) WV-100 [Rev. January 1, 2007] PETITION OF EMPLOYER FOR INJUNCTION PROHIBITING VIOLENCE OR THREATS OF VIOLENCE AGAINST EMPLOYEE (Workplace Violence) Page 4 of 4