IN THE SUPERIOR COURT OF GWINNETT COUNTY STATE OF GEORGIA _________________________________________ Petitioner v. _________________________________________ Respondent * * * * * * * * Civil Action File No: ___________________________________ Prior/Pending Case Nos: ____________________________________ PETITION FOR RELIEF UNDER THE STALKING STATUTE Comes now the Petitioner and submits this Petition for Relief under the Stalking Statute, 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 expressly designated otherwise. Petitioner's Name: Mailing Address: City, State, Zip: Phone Numbers: 2. Respondent: Name: Home Address: City, State, Zip: Phone Numbers: If the Respondent is a resident of the state of Georgia, the Georgia Constitution requires that this action MUST be filed in the County where the Respondent resides. 3. This Court has venue and/or 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 stalking within the State of Georgia or has committed an act of stalking outside of the State of Georgia having an effect inside the State of Georgia, and (next page) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Q:/Magforms\MAG60-05\Petition Stalking TPO ­ September 2014 (1) (2) [] [] the Petitioner is a resident of Gwinnett County, Georgia. the Petitioner is a resident of the State of Georgia and the act of stalking committed by the Respondent occurred in Gwinnett County. 4. This action is brought under the provisions of the Stalking Statute (O.C.G.A. §§ 16-5-94). The Petitioner is a victim of Stalking or Aggravated Stalking as defined in O.C.G.A. § 16-5-90 or § 16-5-91. The Respondent [ ] follows, [ ] places under surveillance, or [ ] contacts the Petitioner at or about a place or places (other than the residence of the Respondent), to wit: __________________________________________ __________________________________________________________________________________________, without the consent of the Petitioner for the purpose of harassing and intimidating the Petitioner. Has the Respondent engaged in a knowing and willful course of conduct directed at the Petitioner causing emotional distress by placing the Petitioner in reasonable fear for the Petitioner's safety or the safety of a member of the Petitioner's immediate family? [ ] YES [ ] NO (CHECK ONE) Has the Respondent established a pattern of harassing and intimidating behavior, and which serves no legitimate purpose? [ ] YES [ ] NO (CHECK ONE) Describe the number of instances when the above-described stalking has occurred: ___________________________ How long has the stalking been going on? __________________________________________________________ [ ] The Respondent's conduct has been committed in violation of a bond to keep the peace posted pursuant to O.C.G.A. § 17-6-110, temporary restraining order, temporary protective order, permanent restraining order, permanent protective order, preliminary injunction, or permanent injunction or condition of pretrial release, condition of probation, or condition of parole. Such order was issued by the ______________ Court of _______________________ County, State of ______________ on , . The specific facts concerning the acts of Stalking/Aggravated Stalking are as follows: (Attach additional sheets and exhibits as necessary, BUT DO NOT WRITE ON THE BACK) 5. 6. The Petitioner alleges that Stalking/Aggravated Stalking has occurred in the past and is reasonably likely to occur in the future for the following reasons: [] [] [] [] The Respondent has made threats of stalking. There is an established pattern of behavior by the Respondent involving acts of stalking as set forth above. The Respondent has a pattern of continued substance abuse which has caused stalking in the past. Other: _______________________________________________________________________________. Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Q:/Magforms\MAG60-05\Petition Stalking TPO ­ September 2014 COURT USE ONLY ­ Intake judge's notes on additional oral testimony given concerning stalking: 7. Petitioner and Respondent are: (CHECK ALL THAT MAY APPLY, IF ANY) [ ] co-workers; [ ] reside in the same neighborhood or apartment complex; [ ] related by blood or marriage; [ ] ex-boyfriend/ex-girlfriend; [ ] students at same school; [ ] former dating acquaintances; or [ ] other relationship: ______________________________________. 8. Petitioner contends that the Respondent should be restrained from committing further acts of stalking. WHEREFORE, the Petitioner requests the following relief be awarded the Petitioner (check all that apply): [] [] that the Respondent be restrained from stalking, harassing or interfering with the Petitioner; that the Respondent be ordered to pay the Petitioner's attorney fees for bringing this action. Furthermore, the Petitioner prays that: (a) A Stalking Ex Parte Temporary Protective Order issue immediately, restraining and enjoining the Respondent from committing acts of stalking against Petitioner; (b) The Court issue a Rule Nisi order requiring the Respondent to appear and show cause why the relief demanded by the Petitioner should not be granted; (c) The sheriff, any deputy sheriff or any other state, county, or municipal law enforcement officer shall implement any order of this Court; and (d) For such other and further relief as this Court deems just and proper. I have read the above Petition and hereby swear or affirm that the allegations made herein are based upon my personal knowledge and are true and correct. ___________________________________________ Petitioner's Signature Sworn to and subscribed before me this ______ day of _____________________________, 20______. _________________________________________ Clerk of Court/Notary Public/Judicial Officer __________________________________________ Petitioner's Printed Name Q:/Magforms\MAG60-05\Petition Stalking TPO ­ September 2014 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com