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Domestic Violence Restraining Order Incident Summary (Packet Attachment) Form. This is a California form and can be use in Sacramento Local County.
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Tags: Domestic Violence Restraining Order Incident Summary (Packet Attachment), FL-E-LP-613, California Local County, Sacramento
Domestic Violence Packet Attachment to Application For
DOMESTIC VIOLENCE RESTRAINING ORDERS
Other Case(s) Involving Child Custody and/or Visitation
1.
I have/
have not participated in another case against the person who is to be restrained which involves child custody
and/or visitation.
2.
Name of Court, which heard, or is hearing, action: ________________________________________________.
3.
The Court's order or judgment regarding child custody and/or visitation was: ___________________________
_________________________________________________________________________________________.
4.
The child (ren) have been living with
Mother
Father since
5.
I have/
have not had an
Emergency Protective Order,
Criminal Temporary Restraining Order, or
Criminal
Restraining Order against the person who is to be restrained.
Partner ____________________________.
(approx. date)
Name of the Court and case number which heard, or is hearing the action:________________________________
6.
Are you currently involved in a dependency case? ____ Yes ____No
Allegations of Abuse
1.
The most recent incident of PHYSICAL abuse by the Defendant was
________________________________.
(approx. date)
Defendant:
hit me on the:
arms
legs
face
head
stomach
back
eye
black 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 me by my hair
choked me
bruises; describe: ______________________________________________________________.
City Police/Sheriff was called;
Defendant was arrested for spousal abuse
Report taken
Other injuries: __________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2.
The second most recent incident of PHYSICAL abuse by the Defendant was ____________________________.
(approx. date)
Defendant:
hit me on the:
arms
legs
face
head
stomach
back
eye
black 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 me by my hair
choked me
bruises; describe:________________________________________________________________
City Police/Sheriff was called;
Defendant was arrested for spousal abuse
Report taken
Other injuries:__________________________________________________________________
________________________________________________________________________________
FL/E-LP-613 (Rev. 1/29/2009)
Domestic Violence Packet Attachment
Page 1 of 2
Mandatory
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________________________________________________________________________________
PLEASE COMPLETE INFORMATION ON REVERSE
3.
The third most recent incident of PHYSICAL abuse by the Defendant was ______________________________.
(approx. date)
Defendant:
hit me on the:
arms
legs
face
head
stomach
back
eye
black 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 me by my hair
choked me
bruises; describe:________________________________________________________________
City Police/Sheriff was called;
Defendant was arrested for spousal abuse
Report taken
Other injuries:________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
4.
Since the last act of violence, explain the delay, if any, in seeking this restraining order:
____________________________________________________________________________________________________
__________________________________________________________________________________
___________________________________________________________________________________________
5.
The most recent incident of threats to
kill me;
beat me;
take child(ren) was on_____________________.
(approx. date)
He/She said_________________________________________________________________________________
__________________________________________________________________________________________.
6.
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 physical abuse:
__________________________________________________________________________________________
__________________________________________________________________________________________.
7.
8.
Other past incidence of physical abuse:__________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
9.
has;
does not have a firearms(s) is registered;
Defendant
hand-gun;
rifle;
The firearm(s) is a (mark all applicable):
I last saw the firearm(s) on _____________________________.
(approx. date)
unregistered;
do not know.
other (describe) ___________________
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)
(signature of person to be protected)
FL/E-LP-613 (Rev. 1/29/2009)
Domestic Violence Packet Attachment
Page 2 of 2
Mandatory
American LegalNet, Inc.
www.FormsWorkflow.com
