CIVIL PROTECTION ORDER DOMESTIC VIOLENCE Adjudicated Hearing Consent w/Admissions Consent w/o Admissions Case No. SUPERIOR COURT OF THE DISTRICT OF COLUMBIA (202) 879-0157 PETITIONER IDENTIFIERS PETITIONER First Name Middle Last Name Date of Birth of Petitioner Other protected persons/DOB v. RESPONDENT IDENTIFIERS RESPONDENT SEX First Name Middle Respondent’s Address RACE DOB HT WT Last Name EYES HAIR SOCIAL SECURITY# DRIVER’S LICENSE # STATE Relationship to Petitioner: Blood; Legal Custody; PDID #: Marriage; !! Having a child in common; Now or previously having shared the same residence; Romantic/dating relationship; Other (specify) THE COURT HEREBY FINDS: That it has jurisdiction over the parties and subject matter, and the Respondent has been provided with reasonable notice and opportunity to be heard. That there is good cause to believe that the Respondent has committed or threatened an intrafamily offense within the meaning of D.C. Code. (Title 16-1001) That it has jurisdiction and that the Respondent has agreed, without admitting to the allegations in the Petition to the entry of this Order. THE COURT HEREBY ORDERS that for a period of 12 months (expiring on ): Respondent shall not assault, threaten, harass, stalk petitioner or his/her child(ren), or destroy Petitioner’s property. Respondent shall stay at least 100 feet away from Petitioner’s person, home, workplace, vehicle, children’s school/daycare, other: Additional terms of this order follow on succeeding pages. WARNING TO RESPONDENT: This order shall be enforced by the courts of any state, the District of Columbia, any U.S. Territory, and may be enforced by Tribal Lands (18 U.S.C. Section 2265). Crossing state, territorial, or tribal boundaries to violate this order may result in federal imprisonment (18 U.S.C. Section 2262). Federal law provides penalties for possessing, transporting, shipping, or receiving any firearm or ammunition (18 U.S.C. Section 922(g)(8). ONLY THE COURT CAN CHANGE THIS ORDER. American LegalNet, Inc. www.USCourtForms.com 2 Respondent shall not contact the Petitioner in any manner, including but not limited to: by telephone, in writing, in any other manner; either directly or indirectly through a third party except under the following conditions: . Temporary custody of the following minor children is awarded to: Petitioner Respondent until further order of this Court or the expiration date of this Order. (Specify names and dates of birth.): Visitation rights with the above minor children are awarded to: Respondent Petitioner under the following conditions: (specify dates, times, person who will pick up and drop off, etc.).The Court finds that the visitation arrangement will adequately protect the child(ren) and the custodial parent from harm inflicted by the other party. Respondent shall vacate the residence at: on or before (date) . The Metropolitan Police Department shall accompany Respondent/Petitioner to retrieve his/her personal belongings from (location) on (date) at (time) safety and a.m./ p.m., and stand by to ensure Petitioner’s shall retrieve Petitioner’s keys from Respondent. The Metropolitan Police Department shall assist with service of process upon the Respondent. Respondent shall provide Petitioner with financial assistance in the amount of $ per month; one time only; other payment schedule: , , for rent/mortgage assistance; attorney’s fees; spousal support; property damage; medical costs; other: Payment shall be made by (date(s)): through the D.C. Superior Court Registry, Room 4201, 500 Indiana Avenue, N.W. Washington, D.C. 20001. Checks will be made payable to the Clerk, D.C. Superior Court. Payments shall be forwarded to Petitioner at (non-confidential address): Possession and use of the following jointly owned property is awarded to: Petitioner Respondent Respondent shall enroll in and complete a counseling program for: domestic violence; parenting skills; family violence; alcohol; other: drug abuse; Respondent shall enroll in designated program(s) TODAY in the Probation Office (CSOSA), Room 1230 of the D.C. Superior Court and submit to a photograph for identification purposes. CSOSA shall make an assessment of each referral and place the respondent into the prescribed level of supervision. Respondent may not possess, purchase, receive or sell any firearm or ammunition (18 U.S.C. § 922). Other: If Respondent has a change of address at any time, s/he immediately must provide the Domestic Violence Clerk’s Office of the D.C. Superior Court with his/her correct, new address. FAILURE TO COMPLY WITH THIS ORDER IS A CRIMINAL OFFENSE AND CARRIES A PENALTY OF 180 DAYS IN JAIL AND/OR A FINE OF $1,000 Respondent was served with a copy in open court. Respondent failed to appear. A DEFAULT Protection Order is issued. The Court finds that there was proper service and notice on the Respondent of the petition, and good cause for the issuance of this order. Respondent shall comply with all conditions of this Protection Order. The respondent has ten days from the service of this order to file a motion to set aside the default judgement. _____________________________________ Respondent’s signature Date _____________________________________ Judge’s/Magistrate Judge’s signature Date Child Support Addendum Attached THIS ORDER IS HEREBY EXTENDED FROM (today’s date): TO Judge’s/Magistrate Judge’s signature , 20 , 20 . Date DIRECTIONS TO LAW ENFORCEMENT OFFICER ENFORCING THIS ORDER This Order was issued in accordance with the requirements of the Full Faith and Credit Provisions of the Violence Against Women Act; Title IV, Subtitle B, Chapter 2 of the Violent Crime Control and Law Enforcement Act of 1994, 18 U.S.C. section 2265, and this Order is valid and enforceable in the District of Columbia and in all other U.S. States, Territories and Tribal Lands. Reporting alleged violations. If the Respondent violates the terms of this Order and there has not been an arrest; the Petitioner may contact the Clerk of the Circuit Court of the county/state in which the violation occurred and complete an affidavit in support of the violation, or the Petitioner may contact the prosecutor’s office for assistance in filing an action for civil or criminal contempt. The prosecutor may decide to file a criminal charge, if warranted by the evidence. American LegalNet, Inc. www.USCourtForms.com CHILD SUPPORT ADDENDUM TO CIVIL PROTECTION ORDER CASE NO. IF Child support in the amount of $ per month shall be paid by: Respondent; Petitioner. Payments shall occur on the day of every month, beginning and shall be made through the D.C. Superior Court Registry, Room 4201, 500 Indiana Avenue, N.W., Washington, D.C. 20001. Checks will be made payable to the Clerk, D.C. Superior Court. The Clerk shall forward payment to the Petitioner at (nonconfidential address): THE COURT HEREBY FINDS: (Check one) The above amount of child support is in accordance with the D.C. Child Support Guideline. The parties have agreed to the above child support amount and the Court has found this amount to be fair and just. Application of the D.C. Child Support Guideline would be unjust or inappropriate in this case (explain): THE COURT HEREBY FINDS: (Check one) Support payments shall be immediately withheld from the earnings or other income of the obligor. There is good cause not to impose immediate withholding from the earnings of the obligor (explain): Petitioner/Respondent acknowledges paternity. Obligor’s Employment Information for Withholding Purposes Name of current employer: Address of current employer: Phone number of current employer: Social security number of obligor: The obligor must notify the Domestic Violence Clerk’s Office of the D.C. Superior Court within 10 days of any change in the above employment information. A withholding order may be changed upon motion from either party to request an adjustment of periodic arrears payments to reflect a change in the obligor’s ability to pay. The obligor shall make all payments directly into the Court Registry until mandatory wage withholding begins. Respondent/ Petitioner shall maintain/obtain health insurance coverage for the minor children and the petitioner/respondent. ________________________________________ Judge’s/Magistrate Judge’s signature Date: American LegalNet, Inc. www.USCourtForms.com