FL/E-LP-613 Domestic Violence Packet Attachment to Application For DOMESTIC VIOLENCE RESTRAINING ORDERS 1. Have you participated in another case against the person who is to be restrained which involves child custody and/or visitation?  Yes  No Name of Court and case number: __________________________________________________________. The Court's order or judgment regarding child custody and/or visitation was: ________________________ ____________________________________________________________________________________. 2. The child (ren) have been living with  Mother  Father  Partner, since ________________________. (approx. date) Are you currently involved in a dependency case? ____ Yes ____No 3. 4.  I have an  Emergency Protective Order,  Criminal Temporary Restraining Order, or  Criminal Restraining Order against the person who is to be restrained. Name of the Court and case number:_______________________________________________________  I have had no previous restraining orders against the person who is to be restrained. 5. The most recent incident of abuse by the Defendant was 6. The second most recent incident of abuse by the Defendant was ________________________________. (approx. date) Defendant:  hit me on the:  arms  legs  face  head  stomach  back  eye  kicked me on the _________________________________________________________.  pushed and/or shoved me:  into wall  to the floor  threatened me with a weapon (specify weapon and describe incident): ________________________________________________________________________.  pulled my hair  strangled me  left bruises; describe: _______________________________________________________.  sexually abused me, describe: ________________________________________________.  City Police/Sheriff was called;  Defendant was arrested Report number: _________________________ Was a report taken?  Yes  No  Other injuries: _____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ____________________________. (approx. date) Defendant:  hit me on the:  arms  legs  face  head  stomach  back  eye  kicked me on the __________________________________________________________.  pushed and/or shoved me:  into wall  to the floor  threatened me with a weapon (specify weapon and describe incident): ________________________________________________________________________  pulled my hair  strangled me  left bruises; describe: _______________________________________________________.  sexually abused me, describe: ________________________________________________.  City Police/Sheriff was called;  Defendant was arrested Was a report taken?  Yes  No Report number: _________________________  Other injuries:_____________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ PLEASE COMPLETE INFORMATION ON REVERSE FL/E-LP-613 (Rev. 3/26/2009) Mandatory Domestic Violence Packet Attachment Page 1 of 2 www.saccourt.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com FL/E-LP-613 7. The third most recent incident of abuse by the Defendant was 8. Since the last act of abuse, explain the delay, if any, in seeking this restraining order: ______________________________________________________________________________________ ____________________________________________________________________________________ _____________________________________________________________________________________ 9. The most recent incident of threats to  kill me;  beat me;  take child(ren) was on_________________. (approx. date) He/She said___________________________________________________________________________ _____________________________________________________________________________________. 10. Defendant took our child(ren) on ____________________ and will not give them back. (approx. date) Defendant has  physically abused  sexually molested the child(ren). Children's Protective Services  is  is not involved. Describe the abuse: _____________________________________________________________________________________ _____________________________________________________________________________________. 11. ___________________________. (approx. date) Defendant:  hit me on the:  arms  legs  face  head  stomach  back  eye  kicked me on the __________________________________________________________.  pushed and/or shoved me:  into wall  to the floor  threatened me with a weapon (specify weapon and describe incident): ________________________________________________________________________  pulled my hair  strangled me  left bruises; describe: _______________________________________________________.  sexually abused me, describe: ________________________________________________.  City Police/Sheriff was called;  Defendant was arrested Was a report taken?  Yes  No Report number: _________________________  Other injuries:_____________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 12. Other past incidence of abuse:__________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 13. has; does not have a firearms(s) which is registered; unregistered; do not know. Defendant hand-gun; rifle; other (describe) ___________________ The firearm(s) is a (mark all applicable): I last saw the firearm(s) on _____________________________. (approx. date) I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: ........................................ (type or print name) FL/E-LP-613 (Rev. 3/26/2009) Mandatory _______________________________________________ (signature of person to be protected) Domestic Violence Packet Attachment Page 2 of 2 www.saccourt.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com