NAME OF PARTY OR ATTORNEY (and state bar number if attorney) ADDRESS WHERE YOU WANT MAIL SENT: FOR COURT USE ONLY TELEPHONE NUMBER (Optional) ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PLAINTIFF(S): DEFENDANT(S): PETITION FOR INJUNCTION PROHIBITING HARASSMENT Application for Temporary Restraining Order CASE NUMBER: (THIS IS NOT AN ORDER) Read the Instructions for Lawsuits to Prohibit Harassment (form CH-150) before completing this form. 1. PERSONS TO BE PROTECTED (List names and ages of all persons including yourself, if applicable, to be protected by this order and their relationship to the party seeking the orders; all named parties must sign this petition): 2. a. Defendant 1 (name): Sex: M F Ht.:____ Wt.:____ Hair color:_____ Eye color:_____ Race:________ Age:____ Date of birth: _________ (Note: If there is more than 1 defendant, complete attachment 2(Form 169A) & attach with identifying information for each.) b. Defendant's residence address (if known): c. Defendant's work address and name of business (if known): Continued in Attachment 2. 3. This action is filed in this county because a. defendant resides in this county. b. defendant has caused physical or emotional injury to plaintiff in this county. c. other (specify): 4. How is it that you know defendant (i.e., landlord/tenant, neighbor, etc.)? (Specify): 5. Defendant has a. threatened to commit acts of violence against plaintiff(s). (Specify in item 19.) b. committed acts of violence against plaintiff(s). (Specify in item 19.) c. not threatened to commit and has not committed any acts of violence. 6. Defendant has committed a series of acts that seriously alarm, annoy, or harass plaintiff(s). (Specify in item 19) 7. Plaintiff(s) have actually suffered substantial emotional distress as a direct result of defendant's conduct described in item 19, and defendant's conduct would have caused a reasonable person to suffer substantial emotional distress. 8. Defendant's continuing course of conduct has been directed specifically against plaintiff and is knowing, willful, not constitutionally protected, and without legitimate purpose. (See Points and Authorities on Page four.) (Continued on reverse) Form Provisionally Approved by the PETITION FOR INJUNCTION PROHIBITING HARASSMENT Code of Civil Procedure, §527.6 Los Angeles Superior Court 76P324K (Rev. January 1, 1998) Page one of four 169 2000 © American LegalNet, Inc. PLAINTIFF (Name): DEFENDANT (Name): (THIS IS NOT AN ORDER) CASE NUMBER: PLAINTIFF(S) REQUEST 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 hearing. Restrained person must not contact, molest, harass, attack, strike, threaten, sexually assault, batter, telephone, send any messages to, follow, stalk, destroy any personal property, disturb the peace, keep under surveillance, or block movements in public places or thoroughfares. 10. STAY-AWAY ORDERS To be ordered now and effective until the hearing Defendant must stay at least (specify):__________yards away from the following persons and places (the addresses of the places are optional and you do not have to reveal them): a. Plaintiff and the other named plaintiffs (names): b. c. d. e. Plaintiff's residence (address optional): Plaintiff's place of work (address optional): Plaintiff's children's school or place of child care (address optional): Other (specify): (address optional): 11. Will granting of any of the stay-away orders in item 10 interfere with defendant's access to defendant's residence or place of employment? (If yes, explain): Yes No 12. Plaintiff(s) 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): 13. ATTORNEY FEES AND COSTS Defendant should be ordered to pay plaintiff's attorney fees and costs as follows (specify): 14. OTHER ORDERS (specify other orders you are requesting): (Continued on next page) [Rev. January 1, 1998] PETITION FOR INJUNCTION PROHIBITING HARASSMENT Page two of four 2000 © American LegalNet, Inc. PLAINTIFF (Name): DEFENDANT (Name): CASE NUMBER: (THIS IS NOT AN ORDER) 15. Plaintiff(s) request that copies of orders be given to the following law enforcement agencies: Law enforcement agency Address 16. a. b. Plaintiff has asked for restraining orders against the defendant before. (Specify county and case number, if known.) Defendant has asked for restraining orders against plaintiff before. (Specify county and case number, if known.) 17. Plaintiff requests additional relief as may be proper. 18. I request that time for service of the Order to Show Cause and accompanying papers be shortened so that they may be served no less than (specify number): days before the date set for the hearing. I need to have the order shortening time because of the facts contained in this application. (Add additional facts if necessary): 19. DESCRIPTION OF CONDUCT Describe in detail the most recent incidents of abuse. State what happened, the dates, and who did what to whom. Describe any injuries. Continued in Attachment 19 (Form 169A). This petition relates to a protective order, restraining order, or a permanent injunction restraining violence or threats of violence, and therefore must be filed without payment of a filing fee under subdivision (h) of § 527 Code of Civil Procedure. (Note: Even if you check this item, you must pay a filing fee if you have checked box "c" under item 5 on page 1, since no violence or threats of violence have been claimed. If you check this item and the court finds there has been no violence or threats of violence, you will be ordered to pay any unpaid fees, and may be guilty of perjury.) 21. Number of pages attached: ________ I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: 20. . . . . . . . . . . . . . . . . . . . . OR . . . . NAME) . . . . . . . . . . . . . . . . . . . PRINT . . . . (TYPE . . . . . . . . . . . . . . . . . . . . OR . . . . NAME) . . . . . . . . . . . . . . . . . . . PRINT . . . . (TYPE . . . . . . . . . . . . . . . . . . . . OR . . . . NAME) . . . . . . . . . . . . . . . . . . . PRINT . . . . (TYPE [Rev. January 1, 1998] < < < (SIGNATURE OF PLAINTIFF) (SIGNATURE OF PLAINTIFF) (SIGNAT