ORI Number _________________ THE SUPERIOR COURT FOR THE COUNTY OF_________________ STATE OF GEORGIA _______________________, Petitioner, v. _______________________, Respondent. : : : : : : Civil Action File No._____________________ STALKING PROTECTIVE ORDER A hearing was held on this matter on ______________________, 20____ at which the Respondent appeared and/or was provided with the opportunity to be heard and the Petitioner requested that the Protective Order entered in this case be continued. Having heard the evidence presented, reviewed the petition and the record concerning this case and for good cause shown, IT IS HEREBY ORDERED AND ADJUDGED: 1. [pco01] [pco02] 2. [pco04] 3. [pco05] The Respondent has knowingly and willfully violated O.C.G.A. § 16-5-90 et seq. and placed the Petitioner in reasonable fear for the Petitioner’s safety. Respondent is hereby enjoined and restrained from doing or attempting to do, or threatening to do any act constituting a violation of O.C.G.A. § 16-5-90 et seq. and of harassing, interfering, or intimidating the Petitioner or Petitioner’s immediate family. Specifically Respondent is hereby enjoined and restrained from ______________________________________ which is a violation of O.C.G.A. § 16-5-90 et seq. and that any future acts committed by the Respondent towards the Petitioner which are in violation of this statute and this Protective Order can amount to AGGRAVATED STALKING, pursuant to O.C.G.A. § 16-5-91, which is a felony. A person convicted of Aggravated Stalking shall be punished by imprisonment for not less than one nor more than ten years and by a fine of not more than $10,000.00. Respondent is enjoined and restrained from approaching within _____ yards of Petitioner and/or Petitioner’s immediate family, and/or residence, place of employment, or school. Respondent is not to have any contact of any type, direct, indirect, or through another person with the Petitioner or her/his immediate family, including but not limited to telephone, fax, e-mail, voice mail, mail, or any other type of contact. American LegalNet, Inc. www.USCourtForms.com CIVIL ACTION FILE NO. ____________________ 4. That these proceedings be filed in the office of the Clerk of this Court. 5. This Order shall remain in effect for up to twelve (12) months from this date. This Order expires on ____________________________, 20____. 6. That this Order applies in every county throughout the state 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. §§ 16-5-94(e) and 19-13-4(d). Law Enforcement may use their arrest powers pursuant to O.C.G.A. §§ 16-5-91 and 17-4-20 to enforce the terms of this Order. 7. That this Court determined that it had jurisdiction over the parties and the subject matter under the laws of the State of Georgia and 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 and this Order shall be presumed valid and pursuant to18 U.S.C. § 2265(a) shall be accorded full faith and credit by any other state or local jurisdiction and shall be enforced as if an Order of the enforcing state or jurisdiction. ONLY the following that are initialed by the JUDGE shall apply: ____ 8. Respondent is to receive appropriate psychiatric or psychological services. ____ 9. Petitioner is awarded costs and attorney fees in the amount of _________. ____ 10. Petitioner/protected party is either a spouse, former spouse, parent of a [pco07] common child, child of Petitioner, child of Respondent, cohabitates or has cohabited with Respondent and qualifies for 18 U.S.C. § 922(g). SO ORDERED this _____ day of ______________________, 20____. ________________________ JUDGE, SUPERIOR COURT __________________ County ________________________ Print or stamp Judge’s name Violation of the above Order may be punishable by arrest. 2 American LegalNet, Inc. www.USCourtForms.com CIVIL ACTION FILE NO. ____________________ 1. 2. 3. 4. NOTICE TO RESPONDENT 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. This Order shall remain in effect unless specifically superceded by a subsequent Order signed and filed, 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 this Court to change or dismiss this Order. If after a hearing, of which the Respondent received notice and opportunity to participate, a protective order is issued which restrains Respondent from harassing, stalking or 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). 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 another person 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 felony aggravated stalking, which carries penalties of imprisonment 3 American LegalNet, Inc. www.USCourtForms.com CIVIL ACTION FILE NO. ____________________ * REMOVE THIS PAGE FROM ORDER * Pursuant to O.C.G.A. Section 19-13-3, Petitioner assisted by Name: _________________________ Address: _______________________ _______________________________ Telephone: _____________________ Note to Judges: 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 may delete or otherwise make inoperative any provision in the standardized form which is not supported by the evidence in the case and in order to comply with the court's application of the law and facts to an individual case. 4 American LegalNet, Inc. www.USCourtForms.com CIVIL ACTION FILE NO. ____________________ RESPONDENT’S IDENTIFYING INFORMATION (please complete as much as possible; one of these must be provided to have the order placed in the National Crime Information Center registry: Respondent’s date of birth OR social security number) Respondent’s social security number is _______________, date of birth is _________, sex ___, color of hair ___________, color of eyes ______________, height _______, weight _____. Respondent’s race is ______. Ethnic background ____________ Respondent drives a _____________________, license tag number _________________ and has a ____(state) driver’s license number ___________. Respondent has distinguishing marks (tattoos, scars, etc.)_____________________. Respondent’s home address ______________________________. and is employed by________________ at _______________________ and works from ____ to ____ PETITIONER’S IDENTIFYING INFORMATION Protected parties ___________________________ DOB ________ sex ____ race ______ ___________________________ DOB ________ sex ____ race ______ ___________________________ DOB ________ sex ____ race ______ ___________________________ DOB ________ sex ____ race ______ ___________________________ DOB ________ sex ____ race ______ “ Transmitted to Georgia Protective Order Registry Date _______ Clerk _______ Rev’d 2/25/05 5 American LegalNet, Inc. www.USCourtForms.com