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Petition For Protective Orders Elder Or Dependent Adult Abuse Form. This is a California form and can be use in Sacramento Local County.
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Tags: Petition For Protective Orders Elder Or Dependent Adult Abuse, 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
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injuries:__________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________________________
PLEASE COMPLETE INFORMATION ON REVERSE
3.
The third most recent incident of PHYSICAL abuse by the Defendant was
______________________________.
Defendant: ! hit me on the: ! arms
! legs
! face ! head
(approx. date)
! 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:
____________________________________________________________________________________
____________________________________________________________________________________
______________
____________________________________________________________________________________
_______
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The most recent incident of threats to ! kill me; ! beat me; was on_____________________.
(approx. date)
He/She
said_________________________________________________________________________________
____________________________________________________________________________________
______.
5.
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
2001 © American LegalNet, Inc.
