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Elder Abuse 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: Elder Abuse Restraining Order Incident Summary (Packet Attachment), FL-E-LP-614, California Local County, Sacramento
Attachment to Application For
PETITION FOR PROTECTIVE ORDERS (Elder or Dependent Adult Abuse)
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:__________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________________________
PLEASE COMPLETE INFORMATION ON REVERSE
FL/E-LP-614 (Rev. 1/29/2009)
Elder Abuse Packet Attachment
Page 1 of 2
American LegalNet, Inc.
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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; was on_____________________.
(approx. date)
He/She said_________________________________________________________________________________
__________________________________________________________________________________________.
8.
Other past incidence of physical abuse:__________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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)
Revised 12//00
FL/E-LP-614 (Rev. 1/29/2009)
FL FRONT CTR/FL FORMS
Elder Abuse Packet Attachment
Page 2 of 2
American LegalNet, Inc.
www.FormsWorkflow.com
