IN THE SUPERIOR COURT OF GWINNETT COUNTY STATE OF GEORGIA _________________________________________ Petitioner v. _________________________________________ Respondent * * * * * * * * Civil Action File No: ___________________________________ Prior/Pending Case No(s): ____________________________________ PETITION FOR RELIEF UNDER THE FAMILY VIOLENCE ACT Comes now the Petitioner and submits this Petition for Relief under the Family Violence Act, as follows: 1. PETITIONER MUST PROVIDE ALL REQUESTED INFORMATION. If unknown, please indicate as such. In the event Petitioner is staying at a CONFIDENTIAL LOCATION, please list an alternate address and alternate phone number(s) for all court notices. Anything filed with the Court is public record unless designated otherwise. Petitioner's Name: Mailing Address: City, State, Zip: Phone Numbers: 2. Respondent: Respondent's Name: Home Address: City, State, Zip: Phone Numbers: 3. This Court has jurisdiction over this matter because: [CHECK ALL THAT MAY APPLY] (a) (b) [] [] the Respondent is a resident of Gwinnett County, Georgia the Respondent is a resident of the State of _______________________________, and the Respondent has committed an act of family violence within the State of Georgia or has committed an act of family violence outside of the State of Georgia having an effect inside the State of Georgia, and [] [] the Petitioner is a resident of Gwinnett County, Georgia. the Petitioner is a resident of the State of Georgia and the act of family violence committed by the Respondent occurred in Gwinnett County. (1) (2) Q:\ MAGFORMS\ MAG 60-14 Petition Relief FV Act Sept. 2014 Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 4. This action is brought under the provisions of the Family Violence Act (O.C.G.A. §§ 19-13-1, et seq.) The parties are related to each other as follows: Check One Relationship Present Spouse [ ] Ceremonial [ ] Common Law Former Spouse Persons living in the same household Persons formerly living in the same household Parents of the Same Children Parent and Child Stepparent and Stepchild Sibling Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable Date Relationship Began Date Relationship Ended Not Applicable 5. The minor children of the parties or children residing with the parties are as follows: Name of Child PROVIDE ONLY THE YEAR OF BIRTH (NOT MONTH OR DAY) Year of Birth: [ ] Both [ ] Petitioner [ ] Respondent Year of Birth: [ ] Both [ ] Petitioner [ ] Respondent [ ] Both [ ] Petitioner [ ] Respondent [ ] Both [ ] Petitioner [ ] Respondent [ ] Both [ ] Petitioner [ ] Respondent [ ] Both [ ] Petitioner [ ] Respondent [ ] Both [ ] Petitioner [ ] Respondent [ ] Both [ ] Petitioner [ ] Respondent [ ] Both [ ] Petitioner [ ] Respondent [ ] Both [ ] Petitioner [ ] Respondent Resides with: Related to: Year of Birth: Year of Birth: Year of Birth: This section MUST be completed in any case in which custody or visitation may be an issue: The present address of the minor children is: [ ] Petitioner's address; [ ] Respondent's address; [ ] Other: ________________________________________________________________________________________ I [ ] have [ ] have not participated as a party, witness, or in any other capacity in any litigation concerning the custody of my children in Georgia or in any other state. I [ ] have [ ] do not have information of any custody proceeding concerning my child(ren) pending in a court of Georgia or any other state. I [ ] know [ ] do not know of any person, not a party to this action, who has physical custody of my child(ren) or claims to have custody or visitation rights with respect to my child(ren). If you answered affirmatively ("I have/know") to any of the above questions you must list and describe all such cases, including the name of each court(s), and the most recent judgment or order: _________________________________________________________________________________________ ___. Q:\ MAGFORMS\ MAG 60-14 Petition Relief FV Act Sept. 2014 Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 6. For a TPO to issue, the Petitioner must demonstrate that the Respondent has committed an act of Family Violence, as defined by law. Petitioner contends that Respondent committed the following acts (you must check at least one, but can explain the facts and circumstances below): [ ] Simple Battery [ ] Battery [ ] Simple Assault [ ] Aggravated Assault [ ] Stalking [ ] Criminal Trespass [ ] Criminal Damage to Property [ ] Other Felonies 7. [ ] Unlawful Restraint [ ] Aggravated Stalking The specific facts concerning the above listed acts of Family Violence are as follows (Attach additional sheets and exhibits as necessary, BUT DO NOT WRITE ON THE BACK): ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ COURT USE ONLY ­ Intake judge's notes on additional oral testimony given concerning violence: 8. The Petitioner alleges that Family Violence has occurred in the past and is reasonably likely to occur in the future for the following reasons: [] [] The Respondent has made threats of future violence/stalking. There is an established pattern of behavior by the Respondent involving acts of family violence as set forth above. The Respondent has a pattern of continued substance abuse which has caused family violence in the past. The Petitioner requests that the Court evaluate certain factors and the history of family violence occurrences which affect the risk of future violence, whic