Civil Action File No: ____________________________ ORI NUMBER:____________________ IN THE SUPERIOR COURT OF GWINNETT COUNTY STATE OF GEORGIA _______________________________________ Petitioner v. _______________________________________ Respondent * * * * * * * * Civil Action File No: ____________________________ [ ] The clerk shall mail a copy of this order to Respondent at last known mailing address, or _________________________ _______________________________ THREE YEAR OR PERMANENT FAMILY VIOLENCE PROTECTIVE ORDER 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 converted to a Permanent Family Violence Protective Order. This Court has determined that it had jurisdiction over the subject matter and the parties. Having heard the evidence presented, reviewed the Motion 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 and the Order issued __________________________, 20 _____, shall be permanent pursuant to O.C.G.A. 19-13-4(C) and have NO expiration date. OR 3.1. This Order shall be in effect for three (3) years and shall expire on ______________________, 20 _____. 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. 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. 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. FV 3 Year or Permanent Protective Order Page 1 of 8 Q:\MAGFORMS\MAG 60-24 July 05 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ 5. [pco02] 6. 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. [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: _____________________________________________________________________ Petitioner=s current workplace is: _________________________________________ The current school(s) is/are: _____________________________________________ _____ 8. [pco01,04] _____ 9. [pco05] _____ 10. 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 _____ FV 3 Year or Permanent Protective Order Page 2 of 8 Q:\MAGFORMS\MAG 60-24 July 05 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ _____ 11. [ ] 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 gross income of the father is:_________________ monthly or $____________ yearly; The gross income of the mother is:________________ monthly or $____________ yearly; The applicable percentages of obligor=s gross income to be considered by the trier of fact to determine child support are: 1 child, 17-23%; 2 children, 23-28%; 3 children 25-32%; 4 children, 29-35%; 5 children, 31-37% In this case child support is being determined for ___________ child/ren and the applicable percentage of gross income to be considered is__________ to __________ percent. The court has considered the existence of special circumstances as has found: [ ] no special circumstance apply; [ ] the following special circumstances exist: ___________________________ _____________________________________________________________ The Court finds that such payments are in compliance with the child support guidelines. FV 3 Year or Permanent Protective Order Page 3 of 8 Q:\MAGFORMS\MAG 60-24 July 05 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ _____ 12. 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 ____________________________________________________. [ ] 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 3 Year or Permanent Protective Order Page 4 of 8 Q:\MAGFORMS\MAG 60-24 July 05 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ ______ 13. 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 3 Year or Permanent Protective Order Page 5 of 8 Q:\MAGFORMS\MAG 60-24 July 05 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 _____ 14. 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. _____ 15. [ ] 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. _____ 16. 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. _____ 17. [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: [ ] to immediately surrender all firearms and ammunition in his/her possession to the Gwinnett County Sheriff=s Office. [ ] to provide to the Court proof that such items have been delivered to a third party and shall remain in the possession of that party until further order of this Court or the expiration of this Judgment, whichever first occurs. FV 3 Year or Permanent Protective Order Page 6 of 8 Q:\MAGFORMS\MAG 60-24 July 05 American LegalNet, Inc. www.FormsWorkflow.com Civil Action File No: ____________________________ It is further ordered as initialed below: _____ 18. IT IS FURTHER ORDERED ____________________________________________________________________ [pco08] _____________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 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 3 Year or Permanent Protective Order Page 7 of 8 Q:\MAGFORMS\MAG 60-24 July 05 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). 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 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 3 Year or Permanent Protective Order Page 8 of 8 Q:\MAGFORMS\MAG 60-24 July 05 American LegalNet, Inc. www.FormsWorkflow.com