ORI NUMBER:____________________ IN THE SUPERIOR COURT OF GWINNETT COUNTY STATE OF GEORGIA _______________________________________ Petitioner v. _______________________________________ Respondent * * * * * * * * Civil Action File No: ____________________________ [ ] The clerk is directed to mail a copy of this document to the Respondent at his/her last known mailing address. FAMILY VIOLENCE PROTECTIVE ORDER TWELVE MONTH DURATION; OR _____ MONTHS DURATION PURSUANT TO O.C.G.A. 19-13-4(C), NOT TO EXCEED ONE YEAR (For cases filed after to 1-1-07) A hearing was held on this matter on _________________________, 20 ____, for which the Respondent had notice as required by law and at which the Respondent appeared and/or had the opportunity to be heard and Petitioner requested that the Protective Order entered in this case be continued. Having heard the evidence presented, reviewed the petition and entire record concerning this case and for good cause shown, 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 to 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. 1-13-6 & 17-4-20 to enforce the terms of this order. 3. This Order shall be in effect for: (circle A or B and complete spaces) A. B. twelve (12) months, OR [ ] _________ months, (not to exceed one year) pursuant to O.C.G.A. 19-13-4( C); from the date of this order, _______________________ until_____________________________. The Clerk of the Superior Court shall submit a copy of this order to the Protective Order Registry in the manner required by law. The clerk shall issue a copy of this Order to the Sheriff of Gwinnett County, Georgia and to the Gwinnett County Police Department, who shall each retain a copy for so long as this Order remains in effect. This Order will remain in effect for the period of time set forth above, at which time it expires, (unless extended by separate order of this Court pursuant to O.C.G.A. ' 19-13-4(c)), or until further order of this Court, whichever first occurs, except with respect to the judgment for attorney=s fees, court costs, and expenses of litigation, which is a final judgment under the Family Violence Act. 4. [pco01] Respondent has violated the Family Violence Act, O.C.G.A.19-13-1 et.seq., by committing family violence has placed the Petitioner in reasonable fear for Petitioner=s safety, and represents a credible threat to the physical safety of Petitioner and/or Petitioner=s child/ren. 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 Petitioner at any place for the purpose of harassing and intimidating the Petitioner. American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ 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 UCS, Chapter 110-A/Domestic Violence, Sections 2261-2266. [ ] 5. [pco02] 6. Alternatively, in lieu of a finding by the court that an act of family violence was committed by the Respondent and/or Petitioner, Petitioner and the Respondent have consented that this Protective Order should be entered by the court, without specifically admitting to the commission of an act of family violence by either party. Respondent is enjoined and restrained from doing or attempting to do, or threatening to do, any act of injury, maltreating, molesting, harassing, harming or abusing the Petitioner=s family or household. 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 received reasonable notice and had the opportunity to be heard before this order was issued 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 shall be enforced as if an Order of the enforcing state, tribe or local jurisdiction and 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 _____ 7. Petitioner is awarded sole and exclusive use and possession of the (family) residence [pco03] located at: __________________________________________________________________ [ ] [ ] The Respondent may return to the residence for the sole purpose of exchanging the minor children of the parties to effectuate any visitation provided herein. [ ] Financing/rental installments shall be paid by: [ ] Petitioner [ ] Respondent [ ] Insurance installments shall be paid by: [ ] Petitioner [ ] Respondent [ ] _____ 8. Alternatively, Respondent is awarded sole and exclusive use and possession of the (family) residence located at: __________________________________________________________________ Utility payments shall be paid by: [ ] Petitioner [ ] Respondent. Respondent is ordered to leave the above listed (family) residence immediately. Members of the Gwinnett County Sheriff's office or any other 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 all and any 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. FV Twelve Month Protective Order Page 2 of 14 Q:\MAGFORMS\MAG 60-09 Jan 07 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ _____ 9. [pco04] Respondent is ordered to stay away from Petitioner=s residence, workplace & school and any subsequent residence, workplace, school and the residence of Petitioner=s, or of the minor children for whom custody is awarded to Petitioner; Said residence is listed as: [ ] the address as listed in # 7, herein above; _____________________________________________________________________ Petitioner=s current workplace is: _________________________________________ The current school(s) is/are: _____________________________________________ _____ 10. Respondent is ordered to provide suitable alternate housing for the Petitioner and/or Petitioner=s children by this date: _____________________________________. _____ 11. [pco01,04] _____ 12. [pco05] _____ 13. Respondent is restrained and enjoined from approaching within _________ yards of Petitioner and/or Petitioner’s minor children. 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 except as specified in this Order; and excepting 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 _____ Respondent is ordered not to interfere with the physical custody of the minor child/ren. _____ [pco06] Initial here ONLY if Respondent is awarded temporary custody of the minor child/ren, namely: ____________________________________ DOB ___________ Sex _____ ____________________________________ DOB ___________ Sex _____ ____________________________________ DOB ___________ Sex _____ ____________________________________ DOB ___________ Sex _____ [ ] The [ ] Petitioner [ ] Respondent shall not consume or be under the influence of any alcohol or drugs, other than over the counter medication or prescription medication taken only as prescribed while in the presence of the minor children. [ ] The [ ] Petitioner [ ] Respondent shall not have any overnight adult guests of the opposite sex, unless related by blood or marriage, in the presence of the minor children. FV Twelve Month Protective Order Page 3 of 14 Q:\MAGFORMS\MAG 60-09 Jan 07 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ [ x ] Neither party shall make any disparaging remarks about the other party to or in the presence of the minor children. [ ] Neither party shall remove the minor children form the jurisdiction of the Court except for temporary trips such as visits to relatives and vacations. [ ] All parties shall successfully complete the program entitled ANavigating Family Change@. See brochure which describes the seminar and is attached to each party=s copy of this order and incorporated herein by express reference. Each party shall successfully complete the seminar within 30 days of the date of service of this order upon that party. Upon a party=s failure to successfully complete the seminar pursuant to this order, the Court may take appropriate action, including, but not limited to, action for contempt. _____ 14. [ ] CHILD SUPPORT [ ] Petitioner; [ ] Respondent; shall pay to [ ] Petitioner; [ ] Respondent; for the support and maintenance of the above minor children the sum of $_____________________, commencing __________________________________, payable: [ ] weekly, on [ ] Sun [ ] Mon [ ] Tue [ ] Wed [ ] Thu [ ] Fri [ ] Sat [ ] Sun [ ] bi-weekly, on [ ] Sun [ ] Mon [ ] Tue [ ] Wed [ ] Thu [ ] Fri [ ] Sat [ ] Sun [ ] semi-monthly, on the _____________ and the _____________ of each month [ ] monthly, on the _____________ of each month. All payments shall be made: _____By an income deduction order; _____ Through DHR Child Support Enforcement; _____ by mail directly to Petitioner; ____ by _________________________________________________. In determining child support the Court finds as follows: [ ] The parties have stipulated and agreed in open court that they have freely and voluntarily agreed to this amount of support and that such amount is in general compliance with the provisions of O.C.G.A. 19-6-15. [ ] The finding and facts set forth in ‘Child Support Computation,’ MAG 60-42, are hereby incorporated by reference herein. [ ] The court considered the facts and evidence set forth in the attached document, generated by the Child Support Calculator, Georgia Department of Human Resources, Child Support Services, which is incorporated by reference herein, consisting of ______ pages. The Court finds that such payments are in compliance with the child support guidelines. Payments shall continue until further order of a Court of competent jurisdiction. If payments are not terminated by order of a Court of competent jurisdiction, then these payments shall continue during the term of this order, not to exceed twelve (12) months, unless otherwise extended pursuant to O.C.G.A. '19-13-4(c). [ ] The Court has insufficient data to determine temporary child support pursuant to the guidelines. Child support is hereby awarded on a temporary basis for the benefit of the minor children pursuant to O.C.G.A 19-6-14. FV Twelve Month Protective Order Page 4 of 14 Q:\MAGFORMS\MAG 60-09 Jan 07 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ _____ 15. The Respondent is ordered to pay temporary support to the Petitioner the sum of $_____________________, commencing _______________________________, payable: [ ] weekly, on [ ] Sun [ ] Mon [ ] Tue [ ] Wed [ ] Thu [ ] Fri [ ] Sat [ ] Sun [ ] bi-weekly, on [ ] Sun [ ] Mon [ ] Tue [ ] Wed [ ] Thu [ ] Fri [ ] Sat [ ] Sun [ ] semi-monthly, on the _____________ and the _____________ of each month [ ] monthly, on the _____________ of each month. All payments shall be made: _____ By an income deduction order; _____ by mail directly to Petitioner; _____ by ____________________________________________________. Payments shall continue until further order of a Court of competent jurisdiction. If payments are not terminated by order of a Court of competent jurisdiction, then these payments shall continue during the term of this order, not to exceed twelve (12) months, unless otherwise extended pursuant to O.C.G.A. '19-13-4(c). [ ] HEALTH INSURANCE [ ] Petitioner [ ] Respondent shall provide and maintain medical/hospitalization insurance coverage [ ] comparable to the present coverage maintained by that party [ ] as follows: __________________________________________________________________ to cover and pay at minimum the same equivalent portion of the medical, drug, clinic, hospital, and outpatient charges incurred for the benefit of [ ] each child [ ] Petitioner [ ] Respondent. The party maintaining said medical insurance shall from time to time hereafter, upon request, furnish to the other party duly signed insurance claim forms or an insurance card which shall be submitted to the requesting party within ten (10) days of the date of said request. If the other party has paid a portion of such bill that is actually covered by insurance, then the party receiving the insurance proceeds shall remit the received insurance proceeds to the other party immediately upon receipt thereof. Medical expenses incurred for the minor child(ren) of the parties which are not covered or paid by insurance shall be paid as follows: [ ] by Petitioner _________________%, [ ] by Respondent ________________%. Medical expenses incurred for the parties which are not covered or paid by insurance shall be paid as follows: [ ] each party pays own, [ ] by Petitioner, [ ] by Respondent, [ ] as follows: ___________________________________________________. Each party shall pay their share of uninsured medical costs within thirty (30) days of the date of mailing of any such bills to that party by regular, first class mail. FV Twelve Month Protective Order Page 5 of 14 Q:\MAGFORMS\MAG 60-09 Jan 07 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ _____ 16. VISITATION [ ] No Visitation [ ] No visitation until _______________________________________________________ [ ] All visitations shall be supervised by a third party as follows: ____________________________________________________________________________ ____________________________________________________________________________ [ ] Petitioner [ ] Respondent shall have the right to visit each child as follows: [ ] Alternate weekends from ________ ___.m. on ____________________ until ________ ___.m. on ____________________, commencing ___________________________________. [ ] Weekdays, on ____________________________, from __________ ___.m. until __________ ___.m. [ ] Thanksgiving from ________ ___.m. on ____________________ until ________ ___.m. on ____________________ [ ] Christmas from ________ ___.m. on ____________________ until ________ ___.m. on ____________________ [ ] The children shall be with the mother on Mother=s Day from 9:00 a.m. until 6:00 p.m. [ ] The children shall be with the father on Father=s Day from 9:00 a.m. until 6:00 p.m. [ ] For a period of ____________ weeks during the children=s summer vacation. Said weeks may be agreed upon by the parties, in writing, prior to May 1. In the event the parties cannot agree, said weeks of summer visitation shall commence_________________________ at _______ ___.m. and shall end __________________________ at _______ ___.m. [ ] The custodial parent shall have an uninterrupted period of ____________ weeks during the children=s summer vacation. Said weeks may be agreed upon by the parties, in writing, prior to May 1. In the event the parties cannot agree, said weeks of summer visitation shall commence ____________________________ at _______ ___.m. and shall end __________________________ at _______ ___.m. [ ] The following holidays from 9:00 a.m. until 6:00 p.m.: [ ] New Years Day [ ] MLK Birthday [ ] Presidents= Day [ ] Easter Sunday [ ] Memorial Day [ ] July 4th [ ] Labor Day [ ] ________________ [ ] ____________ Other: _______________________________________________________________ FV Twelve Month Protective Order Page 6 of 14 Q:\MAGFORMS\MAG 60-09 Jan 07 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ [ ] VISITATION REQUIREMENTS In the event the non-custodial parent intends to exercise visitation rights, he/she shall give at least forty eight(48) hours telephone or written notice to the custodial parent. For all visitation set forth herein, the non-custodial parent shall have the duty to pick up and return each child from and to the following location: (Strict compliance with this visitation provision shall not be a violation of the restraining provisions of this Order. [ ] the residence of the custodial parent [ ] _________________________________________________________________ Unless prior arrangements have been made and agreed to by both parties. With respect to all visitation, the non-custodial parent shall give notice in the event he/she must cancel any visitation previously _____ 17. 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. _____ 18. 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. _____ 19. [ ] 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. _____ 20. A. 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. Vehicle(s) is/are: Make: ________________ Model: _______________; Year _______; Color_________ Financing installments shall be paid by: [ ] Petitioner [ ] Respondent Insurance payments shall be paid by: B. [ ] Petitioner [ ] Respondent Respondent is awarded sole, exclusive temporary possession of the below listed vehicle. The Petitioner 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 Respondent. Vehicle(s) is/are: Make: ________________ Model: _______________; Year _______; Color_________ Financing installments shall be paid by: [ ] Petitioner [ ] Respondent Insurance payments shall be paid by: FV Twelve Month Protective Order [ ] Petitioner [ ] Respondent Page 7 of 14 Q:\MAGFORMS\MAG 60-09 Jan 07 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ _____ 21. 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 + the following items: ______________________________________________________________________ ______________________________________________________________________ [ ] _____ 22. As coordinated and scheduled with the Gwinnett County Sheriff=s Dept. Family Violence Unit, 770.822.3150 / 770.619.6870. FAMILY VIOLENCE INTERVENTION PROGRAM: (24 weeks) (O.C.G.A. 19-13-16.) _____ A. [ ] Petitioner [ ] Respondent shall attend and complete a certified program of family violence intervention. 1. The party(ies) ordered to attend shall: a. b. c. 2. Enroll and commence the course within FIFTEEN (15) days of the date hereof and file written proof of enrollment with the clerk of this court. (See MAG 60-35) Submit a copy of this order to their selected treatment provider. Return to this court for a Compliance Hearing/Contempt of Court hearing as scheduled by the Court. (MAG 60-29). A list of all certified family violence programs is available from: a. b. c. Georgia Commission on Family Violence, 2 MLK Jr. Drive, Room 852, East Tower, Atlanta, GA 30334, 404.657.3412. Website: Ga Dept. of Corrections, http://www.dcor.state.ga.us which contains a link to the list of certified Family Violence Intervention Programs, http://www.dcor.state.ga.us/pdf/certifiedFVIPs.pdf. For your convenience an alphabetical list of local providers, hours and most recent fees is set forth on Q:\MAGFORMS\ MAG 60-18, Certified Intervention Programs. You should reconfirm the information with each program provider as course offerings and fees frequently change. 3. In the event the party fails to attend and complete this program, the party may be held in contempt of court for which the penalty includes fine and/or imprisonment. This matter shall be reviewed by the Court at a Compliance/Contempt of Court hearing, or may be brought to the court=s attention by filing a Motion for Contempt after which a show cause hearing date shall be set and notice of hearing given. The hearing date and time to show compliance with enrollment/attendance & completion of Family Violence Intervention Program shall be scheduled by separate order, Compliance Hearing Order & Notices to Determine Whether Findings of Contempt of Court Order Should Issue. MAG 60-29. The party may show compliance by filing with the Court the Affidavit of Enrollment / Attendance & Completion of Family Violence Intervention Program AT LEAST 24 FV Twelve Month Protective Order Page 8 of 14 Q:\MAGFORMS\MAG 60-09 Jan 07 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ HOURS PRIOR TO THE HEARING date and time. Once properly and timely filed, the party ‘MAY’ be relieved of attending the hearing BUT ONLY IF specifically approved by a signed order of the Court. (See MAG 60-35) A copy of this form is available from the clerk’s office or on the Court’s website, www.gwinnettcourts.com > Family Violence. _____ B. The Court determines and hereby sets forth its reasons why participation in such a program is not appropriate under the facts of this case: (check ALL that apply) [ ] Agreement of the parties, freely and voluntarily made in open court; [ ] The acts alleged and found to have actually occurred do not rise to the level of requiring attendance at a state certified family violence intervention program; [ ] The responsible party is currently enrolled, or has agreed to enroll, in a suitable treatment/counseling program; [ ] The responsible party is incarcerated and is reasonably believed to be unlikely in the foreseeable future to complete attendance requirements. [ ] The responsible party is charged with criminal acts connected with this matter. The court finds that for the reasons of judicial economy, to avoid duplication of services that the criminal justice system can better insure strict compliance with family violence course attendance and completion. [ ] Other factors described with specificity: _______________________________ ______________________________________________________________ ______________________________________________________________ _____ 23. [ ] Respondent [ ] Petitioner; in order to prevent a recurrence of family violence, is ordered to undergo alcohol/drug abuse evaluation at the GRN Court Services Program (Gwinnett-RockdaleNewton Mental Health) and follow the recommended treatment. GRN COURT SERVICES 595 OLD NORCROSS ROAD, SUITE A LAWRENCEVILLE, GA 30045 678-377-3600 The cost of the evaluation is $60.00 which shall be paid by the party ordered to have the evaluation. This cost shall be paid by cash or money order. The party(parties) designated above shall attend and complete any recommended alcohol/drug Intervention or treatment as directed by GRN Court Services. The party shall also return to this court for a Compliance Hearing/Contempt of Court hearing to prove completion of this requirement. (Seem MAG 60-29.) The party may show compliance by filing with the Court the Affidavit of Completion of Alcohol – Drug Evaluation AT LEAST 24 HOURS PRIOR TO THE HEARING date and time. Once properly FV Twelve Month Protective Order Page 9 of 14 Q:\MAGFORMS\MAG 60-09 Jan 07 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ and timely filed, the party ‘MAY’ be relieved of attending the hearing BUT ONLY IF specifically approved by a signed order of the Court. (See MAG 60-36) A copy of this form is available from the clerk’s office or on the Court’s website, www.gwinnettcourts.com > Family Violence. This affidavit shall also include a document verifying the evaluation issued by GRN. _____ 24. 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 Unit. 770.822.3150 / 770.619.6870. _____ 25. Attorney Fees: [ ] Petitioner [ ] Respondent shall pay attorney fees to the [ ] Petitioner=s [ ] Respondent=s attorney in the amount of $____________, at the rate of $_____________ per ___________________, commencing ___________________________. In the event any payment is ten (10) days overdue, the entire remaining balance shall become due instanter. [ ] Each party shall pay their own attorney fees. _____ 26. [pco07] Petitioner/protected party is either a spouse, former spouse, parent of a common child, Petitioner=s child, child of Respondent, cohabitates or has cohabitated with Respondent and qualifies for 18 U.S.C. 922 (g). RESTRICTIONS ON POSSESSION OF FIREARMS Pursuant to 18 U.S.C.A. 922(g)(8) and/or 922(g)(9), the Respondent is prohibited from shipping, transporting, possessing, or receiving any firearm or ammunition which has been shipped or transported in interstate or foreign commerce. Respondent shall be entitled to the immediate return of said items upon the expiration of this order, provided there is no other legal adjudication prohibiting such possession. Respondent is hereby ordered: [ ] The Court has not found to a preponderance of competent evidence that the Respondent is in present possession of firearms or ammunition that require surrender. The Respondent is hereby still given notice that such possession is prohibited. A violation of this provision may subject the Respondent to contempt of court and incarceration as well as violation of federal laws. OR [ ] Respondent was found by the court, to a preponderance of the evidence, to be in possession of firearms and/or ammunition. The Respondent shall IMMEDIATELY surrender all firearms and ammunition in his/her possession to the Gwinnett County Sheriff=s Family Violence Unit, to be held for the duration of the order of the court. 770.822.3150/ 770.619.6870. FV Twelve Month Protective Order Page 10 of 14 Q:\MAGFORMS\MAG 60-09 Jan 07 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ The surrender of all firearms and ammunition shall be done in the manner as directed by the deputy of the Gwinnett County Sheriff’s Family Violence Unit. [ ] The parties have mutually agreed in open court that the Respondent shall surrender all firearms and ammunition to the person listed in the judgment who shall hold them for the duration of this order. The hearing date and time to show compliance with the surrender of all firearms and ammunition shall be scheduled by separate order, Compliance Hearing Order & Notices to Determine Whether Findings of Contempt of Court Order Should Issue. MAG 60-29. The party may show compliance by filing with the Court the Affidavit of Surrender of All Firearms & Ammunition AT LEAST 24 HOURS PRIOR TO THE HEARING date and time. Once properly and timely filed, the party ‘MAY’ be relieved of attending the hearing BUT ONLY IF specifically approved by a signed order of the Court. (See MAG 60-34) A copy of this form is available from the clerk’s office or on the Court’s website, www.gwinnettcourts.com > Family Violence. It is further ordered as initialed below: _____ 27. IT IS FURTHER ORDERED ____________________________________________________________________ [pco08] _____________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ FV Twelve Month Protective Order Page 11 of 14 Q:\MAGFORMS\MAG 60-09 Jan 07 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ ______ 28. DEBTS TO BE PAID BY PETITIONER Petitioner shall henceforth pay the installments connected with the following debts according to their respective terms for the duration of this order: [ ] All debts listed solely in the Petitioner=s name ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Other than as provided herein, neither party shall incur any debts or make use of any credit for which the other party may be held liable by the creditor. _____ 29. DEBTS TO BE PAID BY RESPONDENT Respondent shall henceforth pay the installments connected with the following debts according to the respective terms for the duration of this order: [ ] All debts listed solely in the Respondent=s name ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Other than as provided herein, neither party shall incur any debts or make use of any credit for which the other party may be held liable by the creditor. _____ 30. 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 pending 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. _____ 31. SCOPE OF HEARING: The parties to this action are also the parties to a divorce action pending in the Superior Court of ____________________ County, Civil Action No._______________. A temporary hearing [ ] has; [ ] has not; been scheduled in that action. [ ] This Court has conducted a full hearing on all of the issues which could reasonably expected to be raised by the parties at a temporary hearing in the divorce action. [ ] The Court has conducted a limited hearing for the purpose of defining the rights of the parties pending a temporary hearing in the divorce action. FV Twelve Month Protective Order Page 12 of 14 Q:\MAGFORMS\MAG 60-09 Jan 07 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ IT IS HEREBY ORDERED THAT each of the parties shall abide by the foregoing terms and provisions of this order. Any party who contends that the other party is in contempt of Court may bring the matter back before the Court by filing a Motion for Contempt, under the same case number, with proper service upon the other party. Such motions must be filed prior to the expiration of this Order. Furthermore, an offending party may be subject to criminal prosecution as well. (See below notice.) So ordered this ________ day of __________________________, 20____ at ___________ ___.M. __________________________________________ Judge, Gwinnett Superior Court [ ] by designation Print Name:________________________________ FV Twelve Month Protective Order Page 13 of 14 Q:\MAGFORMS\MAG 60-09 Jan 07 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ CONSENT The parties have consented to the provisions of the above order and agree to comply with the terms and provisions thereof: ____________________________________ Petitioner ____________________________________ Respondent ____________________________________ Attorney for Petitioner _____________________________________ Attorney for Respondent Bar No: _____________________________ Bar 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/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, dismiss this Order. Either party may ask, in writing, or during any hearing, that this Court to change or dismiss this Order. 3. If after a hearing, of which the Respondent received notice and opportunity to participate, a protective order is issued which retrains Respondent from harassing, stalking, threatening an intimate partner, Respondent is prohibited from possessing, receiving, or transporting a firearm or ammunition which has been shipped or transported in interstate or foreign commerce for the duration of the order, 18 U.S.C. 922(g). 4. 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 Twelve Month Protective 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. FV Twelve Month Protective Order Page 14 of 14 Q:\MAGFORMS\MAG 60-09 Jan 07 American LegalNet, Inc. www.FormsWorkflow.com