ORI NUMBER:____________________ IN THE SUPERIOR COURT OF GWINNETT COUNTY STATE OF GEORGIA ___________________________________ Petitioner * * * * * * * * v. ___________________________________ Respondent Civil Action File No: ____________________________ FAMILY VIOLENCE EX PARTE PROTECTIVE ORDER The petition having come on for an ex parte hearing, pursuant to O.C.G.A. 19-13-1 et.seq. that a Protective Order be issued; petitioner alleged that Respondent has committed acts of Family Violence and that Petitioner is in reasonable fear of the Petitioner’s safety (and the safety of Petitioner’s child(ren), and the Court having read and considered the petition and having heard the sworn testimony of the Plaintiff, the Court finds probable cause exists that family violence has occurred in the past and may occur in the future. IT IS HEREBY ORDERED AND ADJUDGED THAT: 1. These proceedings be filed in the office of the Clerk of this Court. 2. This Order applies in every county throughout the state of Georgia and it shall be the duty of every court and every law enforcement official to enforce and carry out the provisions of this order pursuant to O.C.G.A. 19-13-4(d). Law Enforcement officers may use their arrest powers pursuant to O.C.G.A. 19-13-6 & 17-4-20 to enforce the terms of this order. 3. A copy of this order be given to law enforcement and the Respondent be served with a copy of this Order the Petition for Temporary Protective Order instanter. 4. The Petitioner and Respondent named herein shall appear before the Superior Court of Gwinnett County, on the ______day of _____________________________ 20_____, at ________o'clock ____.m. at the Court Annex, 2nd Floor, Gwinnett County Detention Center, 2900 University Parkway, Lawrenceville, Georgia, 30043 Courtroom 4 /_______, to show cause why the demands of the Petitioner should or should not be granted. (Absent a consent agreement, the Court ordinarily will not enter a mutual protective order on issues connected with O.C.G.A. 19-13-4(a)(1), (a)(2), (a)(5), (a)(9) or (a)(11), or any combination thereof, unless the Respondent has filed a verified petition as a counter-petition pursuant to O.C.G.A. 19-13-3 no later than three days, not including Saturdays, Sundays, and legal holidays, prior to the hearing and the provisions of O.C.G.A. 19-13-3 have been satisfied.) 5. Respondent is hereby restrained and enjoined from doing, or attempting to do, or threatening to do, any act of injury, maltreating, molesting, following, harassing, harming, abusing or stalking the Petitioner and the Petitioner’s minor child(ren), if any. Respondent is not to interfere with Petitioner’s travel, transportation or communication. The Respondent shall not follow, place under surveillance, or contact the Plaintiff at any place for the purpose of harassing and intimidating the Plaintiff. Any violation of this order may be considered a violation of O.C.G.A. 16-5-90 and may subject the Respondent to prosecution for Aggravated Stalking, in violation of O.C.G.A. ' 16-5-91, a felony; and Federal Law, Title 18 U.C.S., Chapter 110-A/Domestic Violence, Sections 2261-2266. [pco01] Q:\MAGFORMS\MAG 60-08 Jan 07 1 American LegalNet, Inc. www.FormsWorkflow.com 6. Respondent is enjoined and restrained from doing or threatening to do any act of injury, maltreating, molesting, harassing, harming or abusing the Petitioner’s family or household. [pco02] 7. This Court has determined that it had jurisdiction over the parties and the subject matter under the laws of this state of Georgia and the Court ordered that the Respondent be given reasonable notice and opportunity to be heard sufficient to protect the Respondent’s due process rights. This order shall be presumed to be valid and pursuant to 18 U.S.C. 2265(a) shall be accorded FULL FAITH AND CREDIT by any other state, tribe or local jurisdiction as if an Order of the enforcing state, tribe or jurisdiction. The Petitioner has validly filed this Family Violence Ex Parte Protective Order; therefore, this Order is legally enforceable by any appropriate law enforcement official or court of any State pursuant to 18 U.S.C.A. ' 2265. ONLY THE FOLLOWING PROVISIONS APPLY THAT ARE INITIALED BY THE JUDGE _____ 8. [pco03] That until further order by this Court, Petitioner is awarded sole and exclusive use and possession of the (family) residence located at: __________________________________________________________________________ _____ 9. Respondent is ordered to leave the above listed (family) residence immediately. The members of the Gwinnett County Sheriff's office or any other duly authorized law enforcement officer are ordered to: [ ] Assist the Petitioner in returning to this residence; [ ] Remove and evict the Respondent from this residence, together with Respondent’s clothing, personal effects, prescription medication, and tools of his or her trade or profession; [ ] Require Respondent to surrender to law enforcement any and all keys, garage door openers and other security devices to the (family) residence and to insure that these items are delivered to Petitioner. [ ] Effectuate the custody placement of the minor children as set forth herein; [ ] Assist the Petitioner in removing from the residence the Petitioner's clothing and personal effects, together with those of Petitioner’s children, if any. _____ 10. Respondent is ordered to provide suitable alternate housing for the Petitioner and/or Petitioner’s children by this date: _____________________________________. _____ 11. Petitioner’s address is ordered to be kept confidential. _____ 12. Respondent is ordered to stay away from: (1) Petitioner’s residence, workplace & school and any subsequent residence, workplace, school of Petitioner; (2) the residence, workplace & school, and any subsequent residence, workplace, school of the minor children whose custody is awarded to Petitioner; Said residence is listed as: [ ] the address as listed in # 8, herein above; [pco04] _______________________________________________________________________ Petitioner’s current workplace is: ___________________________________________ The current school(s) is/are: _______________________________________________ _____ 13. [pco1,04] Until further order of this Court, Respondent is restrained and enjoined from approaching within ______ yards of Petitioner and/or the minor children of the Petitioner. MAG 60-08 FV Ex Parte Protective Order Jan 07 2 American LegalNet, Inc. www.FormsWorkflow.com _____ 14. [pco05] _____ 15. Civil Action File No: ____________________________ Respondent is ordered to not have any contact, direct or indirect or through another person with Petitioner by telephone, pager, fax, e-mail or any other means of communication excepting as specified in this Order; and excepting any communication with any attorney representing Petitioner. Petitioner is awarded temporary custody of the minor child(ren), namely: [pco09] ______________________________________ DOB _____________ Sex _____ ______________________________________ DOB _____________ Sex _____ ______________________________________ DOB ______________ Sex _____ ______________________________________ DOB ______________ Sex _____ ______________________________________ DOB ______________ Sex _____ Unless otherwise permitted by order of this court, the Respondent shall not have any contact with these minor children until further hearing and order of this Court. Respondent is ordered not to interfere with the physical custody of the children. _____ [pco06] Check here ONLY if Respondent is awarded temporary custody of the minor child(ren), namely: ______________________________________ Sex _____ ______________________________________ DOB _____________ Sex _____ ______________________________________ DOB ______________ Sex _____ ______________________________________ DOB ______________ Sex _____ ______________________________________ _____ 16. DOB _____________ DOB ______________ Sex _____ [ ] Reserved until hearing after notice to both parties; or [ ] The Respondent is ordered to pay temporary child support for the minor children to Petitioner in the amount of $ __________ every _______________________, beginning, ________________________. All payments shall be made: _____ By an income deduction order; _____ To the child support receiver; _____ by mail directly to Petitioner; _____ by ____________________________________________________. _____ 17. [ ] Reserved until hearing after notice to both parties; [ ] The Respondent is ordered to pay temporary support to the Petitioner in the amount of $ __________ every _______________________, beginning, __________________. All payments shall be made: _____ By an income deduction order; _____ To the child support receiver; _____ by mail directly to Petitioner; _____ by ____________________________________________________. MAG 60-08 FV Ex Parte Protective Order Jan 07 -3American LegalNet, Inc. www.FormsWorkflow.com _____ 18. Civil Action File No: ____________________________ Respondent, only when accompanied by a law enforcement officer, shall be able to remove his/her clothing, personal effects, prescription medication, and tools of his or her trade or profession as follows: ____________________________________________________________________ ____________________________________________________________________ [ ] As coordinated and scheduled with the Gwinnett County Sheriff’s Dept. Family Violence Unit, 770.822.3150 / 770.619.6870. _____ 19. Both parties are hereby enjoined and restrained from transferring, selling, pledging as collateral for a loan, contracting to sell, concealing, or otherwise disposing of or removing from the jurisdiction of this Court, any of the property belonging to the parties, the children of the parties, pets of the parties, except in the ordinary course of business or for the necessities of life. _____ 20. [ ] Respondent [ ] Petitioner [ ] Both Respondent & Petitioner is/are ordered not to disconnect or have disconnected the home utilities, including but not limited to electricity, gas, water, telephone; change or have changed, or cancel, or have canceled, auto, health, or life insurance for Respondent, Petitioner, Petitioner’s children, Respondent’s children, or interfere with his/her/their mail. _____ 21. Petitioner is awarded sole, exclusive temporary possession of the below listed vehicle. The Respondent shall not exercise any control over such vehicle. All keys, proof of insurance and registration to this vehicle shall be surrendered to law enforcement and law enforcement shall immediately turn said items over to Petitioner. No changes shall be made to any existing insurance coverage on the vehicle. Vehicle(s) is/are: Make: ________________ Model: _______________; Year _______; Color_________ [ ] _____ 22. As coordinated and scheduled with the Gwinnett County Sheriff’s Dept. Family Violence Unit, 770.822.3150 / 770.619.6870. Petitioner shall be allowed to remove the following property from the family residence for Petitioner and/or Petitioner’s children’s use: his/her/their clothing, personal effects, prescription medication, and tools of his/ her trade or profession and the following items: ____________________________________________________________________ ____________________________________________________________________ [ ] _____ 23. As coordinated and scheduled with the Gwinnett County Sheriff’s Dept. Family Violence Unit, 770.822.3150 / 770.619.6870 Respondent shall be required to return the following property for Petitioner and/or Petitioner’s children’s use: ______________________________________________ ___________________________________________________________________ on or before the following date: __________________________________________. The return of the property shall be coordinated and scheduled with the Gwinnett County Sheriff’s Dept. Family Violence Unit770.822.3150 / 770.619.6870. MAG 60-08 FV Ex Parte Protective Order Jan 07 American LegalNet, Inc. www.FormsWorkflow.com -4- Civil Action File No: ____________________________ IT IS FURTHER ORDERED: _____ 24. [pco08] Other:_________________________________________________________________ ________________________________________________________________________________________ _______________________________________________________________________ _____ 25. Each party shall complete, notarize and file with this Court a true and correct Domestic Relations Financial Data Sheet before the hearing date set forth above. If child support is to be determined, then the parties MUST ALSO COMPLETE MAG 20-42, Child Support Computation prior to the assigned court date. As of January 1, 2007, Child Support Computation REQUIRES the use of the internet and/or the use of an electronic worksheet downloaded to a computer. Computer access is available for ‘free’ at any branch of the Gwinnett Library system or at the Gwinnett County Law Library, Gwinnett Justice & Administration Center, 75 Langley Drive, Lawrenceville, GA 30045. Parties and/or their lawyers should go to http://www.georgiacourts.org/csc/ to find the proper electronic worksheet. Parents should use The Guided Electronic Worksheet. Lawyers, Mediators, and other Professionals should use The Practitioner’s Electronic Worksheet. Anyone can use The Downloadable Electronic Worksheet. Alternatively, go to https://www.services.georgia.gov/dhr/cspp/do/public/SupportCalc to find your proper electronic worksheet. In any contested case, the parties shall submit to the Court their proposed findings regarding the gross incomes of the father and the mother, the presence or absence of special circumstances, and the amount of child support. This may be accomplished through the use of the form CHILD SUPPORT COMPUTATION, available from the Clerk of Court OR through the use of the appropriate electronic worksheet(s). _____ 26. REFERRAL TO VICTIM SERVICES & SAFETY PLANNING GUIDANCE [ ] Petitioner [ ] Respondent shall immediately seek victim services and safety planning guidance from the Partnership Against Domestic Violence -- 770.963.9799 or 404.873.1766. Information on safety planning has been given to said party. In the event there is a ending misdemeanor case connected with this action, this party shall contact the Solicitor’s office, 770.822.8300, victim-witness services. In the event there is a pending felony case connected with this action, this party shall contact the District Attorney’s office, 770.822.8400, victim-witness services. _____ 27. Respondent shall immediately attend evaluation, treatment and counseling through: _____ Gwinnett Court Services -- 770. 682.2933 -- for (alcohol)(drug)(violence) counseling or through another equivalent professional treatment program. SO ORDERED, this _______day of ___________________________, 20______ at ___________ ___.M. ______________________________________ Judge, Gwinnett Superior Court [ ] by designation Print Name:________________________________ MAG 60-08 FV Ex Parte Protective Order Jan 07 -5American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ Violation of this Order May Be Punishable By Arrest Notice to Respondent 1. Violation of this Order may result in immediate arrest and criminal prosecution that may result in jail time and/or fines and/or may subject you to prosecution and penalties for contempt of court. 2. This Order shall remain in effect unless specifically superseded by a subsequent signed and filed Order, by operation of law, or by Order of Dismissal, whichever occurs first. Only this Court can void, modify, or dismiss this Order. Either party may ask, in writing, or during any hearing, that this Court change or dismiss this Order. 3. A person commits the offense of Aggravated Stalking when such person, in violation of a temporary or permanent protective Order prohibiting this behavior follows, places under surveillance, or contacts Petitioner on public or private property for the purpose of harassing and intimidating the other person. This activity can subject the Respondent to arrest and prosecution for the felony Aggravated Stalking, which carries penalties of imprisonment for not less than 1 year nor more than 10 years and a fine up to $10,000.00. Note: This form is promulgated as a Uniform Superior Court Rule under the auspices of O.C.G.A. 19-13-53. To order a specific provision, please initial in the space provided. The court should delete or otherwise make inoperative any provision in the standardized form which is not supported by the evidence in the case or in order to comply with the court’s application of the law and facts to an individual case. [ ] Transmitted to Georgia Protective Order Registry: Date Submitted by Deputy Clerk: By: __________________________________________, Deputy Clerk This is to certify this is a true and correct copy of the foregoing Family Violence Ex Parte Order, as the same appears of record in Gwinnett Superior Court . Given my hand and seal of this court, this _______ day of ___________________________, 20_______. By: _________________________________________, Deputy Clerk, Superior Court, Gwinnett County, GA -6- American LegalNet, Inc. www.FormsWorkflow.com