COURT PETITIONER PARISH/CITY OF V. STATE OF LOUISIANA DIVISION: FILED: DEFENDANT NUMBER: CLERK: PETITION FOR PROTECTION FROM ABUSE Pursuant to La. R.S. 46:2131, et seq. or La. R.S. 46:2151 The petition of , born your name month, day, year a resident of the State of Louisiana, respectfully represents: Paragraph 1 Petitioner files this petition on behalf of: a. ____ Petitioner, and/or b. ____ Minor child(ren) as follows: Name Relationship to petitioner Name DOB Relationship to petitioner Name DOB Relationship to petitioner Name DOB Relationship to petitioner Name DOB Relationship to petitioner Name c. DOB DOB Relationship to petitioner ____ Alleged incompetent: Paragraph 2 a. ____ Petitioner requests that his/her address, or that of the minor child(ren) or alleged incompetent, remain confidential to the court and files the address pursuant to La. R.S. 46:2134(B). (Ask clerk of court for the Confidential Address Form.) OR b. ____ Petitioner’s current address: No. & Street Apt. No. City c. State Zip Code ____ The minor child’s or alleged incompetent’s current address: No. & Street Apt. No. City State Zip Code Paragraph 3 , defendant, resides in Parish Abuser’s Name at No. & Street Apt. No. City State Zip Code LPOR B Page 1 of 7 v.5.1 Paragraph 4 This Court is the proper venue for this action because: The marital domicile is located in Parish. The household is located in Parish. The defendant resides or is domiciled in Parish. The abuse occurred in Parish. The petitioner resides or is domiciled in Parish. (Do not fill this out if address is to remain confidential.) Paragraph 5 The protected person(s) is related to the defendant as: (check all that apply) ___ Current or former spouse ___ Current or former dating partner ___ Current or former unmarried intimate cohabitant ___ Parent, stepparent, or foster parent ___ Child, stepchild, or foster child ___ Grandparent or grandchild ___ Child of defendant’s current or former intimate ___ Other: partner Paragraph 6 ____ A suit for divorce between the parties is not pending. ____ A suit for divorce between the parties is pending (fill out page 7 of this form, “Addendum”) NOTE: If you were NOT the petitioner in the divorce suit, use form LPOR B-R entitled “Petition for Protection From Abuse, (Filed by the Defendant in the Pending Action as Petitioner-in-reconvention)” instead of this one. ____ There is a suit for custody pending involving children named in this petition (fill out page 7 of this form, “Addendum”). ____ There is a custody order in effect involving children named in this petition (fill out page 7 of this form, “Addendum”, or attach a copy of the order if available). Paragraph 7 ____ The protected person(s) and defendant have child(ren) in common. Paragraph 8 a. Defendant abused protected person(s) in the following manner: ___ Slapped protected person(s) ___ Threatened protected person(s) with bodily harm ___ Punched protected person(s) ___ Threatened protected person(s)’ life ___ Choked protected person(s) ___ Threatened protected person(s) with a weapon ___ Shoved protected person(s) ___ Abused petitioner’s child(ren) or ___ Kicked protected person(s) ___ Stalked protected person(s) alleged incompetent ___ Other: LPOR B Page 2 of 7 v.5.1 b. The facts and circumstances of this abuse are as follows: The most recent incident of abuse which caused petitioner to file this petition happened on or about the b. day of , , at which time the defendant did Past incidents: Paragraph 9 Because of the immediate and present danger of abuse, petitioner requests that an ex parte Temporary Restraining Order be issued immediately without bond: a. ____ prohibiting defendant from abusing, harassing, stalking, following, or threatening the protected person(s) in any manner whatsoever. This prohibition includes the use, attempted use, or threatened use of force or physical violence that would reasonably be expected to cause bodily injury. b. ____ prohibiting the defendant from contacting the protected person(s) personally, electronically, by phone, in writing, or through a third party, without the express written permission of this court. c. ____ prohibiting defendant from going within one hundred (100) yards of the residence, apartment complex, or multiple family dwelling of the protected person(s) located at: __________________________________________________________________ No. & Street Apt. No. City State Zip Code LPOR B Page 3 of 7 v.5.1 d. ____ ordering the defendant to stay away from the protected person(s)’ place of employment/school and not to interfere in any manner with such employment/school located at: __________________________________________________________________ Employment/School Address City State Zip Code __________________________________________________________________ Employment/School e. Address City State Zip Code ____ granting the petitioner or protected person(s) the use of the residence located at: __________________________________________________________________ No. & Street Apt. No. City State Zip Code to the exclusion of defendant by evicting defendant and ordering the defendant to surrender any keys to that residence to the petitioner, and ordering (law enforcement agency) to evict the defendant. Said residence is: ____ jointly owned by defendant and petitioner or protected person(s). ____ jointly leased by defendant and petitioner or protected person(s). ____ solely leased by defendant who has a duty to support petitioner or protected person(s). (NOTE: If solely owned by defendant AND petitioner is awarded custody of child(ren) of the parties, check appropriate item in Paragraph 10. ____ solely owned or leased by petitioner or protected person(s). Presently occupied by f. ____ ordering the defendant not to damage any belongings of the protected person(s), not to shut off any utilities, telephone service, or mail delivery to the protected person(s), or in any way interfere with the living conditions of the protected person(s). g. ____ granting petitioner or protected person(s) the use and possession of the following property jointly or solely owned or leased by petitioner or protected person(s)(state location of each item by street address and who is presently in possession). for the following reasons: And ordering ___________________________ (law enforcement agency) to accompany petitioner to where the above listed property is located to allow petitioner to take possession of the property. h. ____ prohibiting either party from transferring, encumbering, or otherwise disposing of property jointly owned or leased, except in the normal course of business or necessary for the support of the petitioner and/or the minor child(ren) or alleged incompetent. i. ____ awarding the temporary custody of the minor child(ren) or alleged incompetent, to petitioner; the minor child(ren) or alleged incompetent is currently in the physical . custody of j. ____ ordering a representative of (law enforcement agency) to accompany petitioner to where the minor child(ren) or alleged incompetent mentioned above is/are currently and to effect petitioner obtaining physical custody of said child(ren) or alleged incompetent. k. ____ prohibiting defendant from interfering with the custody of the minor child(ren) or alleged incompetent. LPOR B Page 4 of 7 v.5.1 l. ____ allowing to return to the residence at a date and time to be agreed upon by petitioner and law enforcement agency, to recover his/her personal clothing and necessities, only if s/he is accompanied by a law enforcement officer to ensure the protection and safety of the parties. NO FORCED ENTRY ALLOWED. m. ____ ordering a representative of agency) to accompany personal clothing and necessities. (law enforcement to the family residence to recover her/his Paragraph 10 Petitioner desires that a rule issue herein ordering defendant to show cause why the orders requested in Paragraph 9 should not be made into protective orders, and why defendant should not also be ordered: ___ to pay petitioner a reasonable amount of child support in accordance with Louisiana Law. ___ to pay petitioner a reasonable amount of spousal support (alimony). ___ to seek professional counseling. ___ to pay costs of court in this matter. ___ to pay attorney fees. ___ to pay evaluation fees. ___ to pay expert witness fees. ___ to pay cost of medical and/or psychological care for the petitioner, minor child(ren), and/or alleged incompetent, necessitated by the domestic violence. ___ to vacate the residence or household, thereby granting petitioner possession thereof. ___ other: . PRAYER WHEREFORE, petitioner prays that service and citation issue herein, and: (check all that apply) ___ that ex parte orders requested in Paragraph 9 be granted. ___ a rule issue to show cause why protective orders as requested in Paragraph 10 should not be granted. ___ defendant be cast with costs. ___ defendant be advised of penalties for violating Abuse Prevention Orders. ___ all other equitable relief as the court deems proper and necessary. Respectfully submitted by, PETITIONER, IN PROPER PERSON PLEASE SERVE DEFENDANT: personally at his/her home or place of employment at the following address: or LPOR B Page 5 of 7 v.5.1 AFFIDAVIT/VERIFICATION STATE OF LOUISIANA PARISH OF BEFORE ME, the undersigned Notary Public, duly commissioned and qualified in and for the state and parish aforesaid, personally came and appeared , Petitioner in the foregoing Petition for Protection from Abuse, who, after being duly sworn by me, did depose and say that s/he has read the allegations contained therein and declared them to be true and correct to the best of her/his knowledge, information, and belief. Petitioner further said that s/he believes that the defendant poses a threat to petitioner’s safety and/or to the child(ren) or to others for whom petitioner has requested relief. Petitioner further said that s/he is aware that any false statement made under oath contained in the foregoing petition and this affidavit shall constitute perjury and shall be punishable by a fine of not more than one thousand dollars ($1,000.00), or by imprisonment, with or without hard labor, for not more than five (5) years, or both. PETITIONER SWORN TO AND SUBSCRIBED before me, Notary Public, on the , 200 day of , Louisiana. , at NOTARY PUBLIC LPOR B Page 6 of 7 v.5.1 ADDENDUM Fill out the following ONLY if directed to do so in Paragraph 6 on page 2 of this petition: Divorce suit pending between parties: Suit Name: ________________________________________________________ Suit Number:_______________________ Division: ______________________ Court: ____________________________________________________________ Date of last hearing:______________ Date of next hearing:_________________ Custody suit pending involving children named in this petition: Suit Name: ________________________________________________________ Involving children (names): ___________________________________________ __________________________________________________________________ Suit Number:_______________________ Division: ______________________ Court: ____________________________________________________________ Date of last hearing:______________ Date of next hearing:_________________ Custody order in effect involving children named in this petition (attach copy if available): Involving children (names): ___________________________________________ __________________________________________________________________ Date Order Signed by Court: _____________ Division: _____________________ Court: ____________________________________________________________ Custody terms/assignment: ___________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ LPOR B Page 7 of 7 v.5.1 LOUISIANA UNIFORM ABUSE PREVENTION ORDER Case No. Order of Protection G G G T.R.O. P.O./Preliminary or Permanent Injunction Modified P.O./Preliminary or Permanent Injunction Court:___________________________________ City/Parish Louisiana PETITIONER First State PETITIONER IDENTIFIERS Middle/Maiden Last Petitioner seeks protection for: G self Date of Birth G other(s) List other(s) name & date of birth: __________________________________________ __________________________________________ __________________________________________ __________________________________________ V. DEFENDANT DEFENDANT IDENTIFIERS SEX First Middle RACE DOB HT WT EYES HAIR SOCIAL SECURITY # Last Relationship of Protected Person(s) to Defendant: (check all that apply) G current or former spouse G current or former unmarried intimate cohabitant G child, stepchild, or foster child G child of defendant’s current or former intimate partner G current or former dating partner G parent, stepparent, or foster parent G grandparent or grandchild G other: ____________________________________ DRIVERS LICENSE # STATE EXP DATE Defendant’s Address: _____________________________________ _____________________________________ THE COURT HEREBY FINDS: That it has jurisdiction over the parties and subject matter, and the defendant has been or will be provided with reasonable notice and opportunity to be heard. Additional findings of this court are as set forth below. THE COURT HEREBY ORDERS: That the above named defendant be restrained from committing further acts of abuse or threats of abuse. Additional terms of this order are as set forth on the following pages. The terms of this order shall be effective until (mm/dd/yy). WARNINGS TO DEFENDANT: This order shall be enforced, even without registration, by the courts of any state, the District of Columbia, any U.S. Territory, and may be enforced by Tribal Lands (18 U.S.C. Section 2265). Crossing state, territorial, or tribal boundaries to violate this order may result in federal imprisonment (18 U.S.C. Section 2262). Federal law provides penalties for possessing, transporting, shipping, or receiving any firearm or ammunition (18 U.S.C. Section 922(g)(8)). See further notice on last page of this order. Only the court can change this order. LPOR 1 Page 1 of 5 v.5.1 LOUISIANA UNIFORM ABUSE PREVENTION ORDER DIVISION: ____________ DOCKET NO.__________ FILED: _______________ COURT NAME AND PARISH/CITY: CLERK: ______________ TEMPORARY RESTRAINING ORDER Pursuant to: G La. R. S. 46:2131, et seq. G La. R.S. 46:2151 G La. Ch. C. Art. 1564, et seq. PETITIONER’S NAME: __________________________________________________________ First Maiden/Middle Sex: G F Date of Birth ______/______/______ mo./ day / yr. Last GM Race: ______________ G On behalf of (name, date of birth, and relationship to petitioner) _________________________ ________________________________________________________________________________ V. DEFENDANT’S NAME: ___________________________________________________________ Alias: ______________ Date of Birth:______/_____/_____ Sex: G F mo./ day / yr. GM Race: ______ Address: ________________________________________________________________________ No. & Street Apt. No. City State Zip Code Social Security #: _________________ Dr. Lic. # ________________ State ____ Exp. ___/___/___ The protected person(s) is related to the defendant as: (check all that apply) G current or former spouse G current or former unmarried intimate cohabitant G child, stepchild, or foster child G child of defendant’s current or former intimate partner G current or former dating partner G parent, stepparent, or foster parent G grandparent or grandchild G other: ______________________ G The protected person and the defendant have a child(ren) in common. IT IS ORDERED THAT THE DEFENDANT BE SERVED WITH A COPY OF THIS ORDER. THE COURT FINDS THAT THE ALLEGATIONS PRESENTED CONSTITUTE AN IMMEDIATE AND PRESENT DANGER OF ABUSE, THAT THE PETITIONER HAS GOOD AND REASONABLE GROUNDS TO FEAR FOR HER/HIS SAFETY OR THAT OF A CHILD OR ALLEGED INCOMPETENT, THUS THE COURT ISSUES THE FOLLOWING ORDERS, WITHOUT A HEARING: (only orders checked and initialed shall apply) ____ G 1. THE DEFENDANT IS ORDERED NOT TO abuse, harass, stalk, follow, or threaten the protected person(s) in any manner whatsoever. This prohibition includes the use, attempted use, or threatened use of force or physical violence that would reasonably be expected to cause bodily injury. ____ G 2. THE DEFENDANT IS ORDERED NOT TO contact the protected person(s) personally, electronically, by phone, in writing, or through a third party, without the express written permission of this court. ____ G 3. THE DEFENDANT IS ORDERED NOT TO go within one hundred (100) yards of the residence, apartment complex, or multiple family dwelling of the protected person(s) located at: _________________________________________________________________________ No. & Street Apt. No. City State Zip Code LPOR 1 Page 2 of 5 v.5.1 Docket No. ________________ ____ G 4. THE DEFENDANT IS ORDERED TO STAY AWAY from protected person(s)’ place of employment/school and not to interfere in any manner with such employment/school located at: __________________________________________________________________________ Employment/School Address City State Zip Code __________________________________________________________________________ Employment/School ____ Address City State Zip Code G 5. THE COURT GRANTS THE PETITIONER or protected person(s) the use of the residence located at: __________________________________________________________________________ No. & Street Apt. No. City State Zip Code to the exclusion of defendant by evicting defendant. The Court orders the defendant to surrender any keys to that residence to the petitioner. ________________________ (law enforcement agency) is ordered to evict the defendant. ____ G 6. THE COURT GRANTS THE PETITIONER or protected person(s) the use and possession of the following property: ____ G 7. THE COURT ORDERS a representative of _________________________(law enforcement agency) to accompany petitioner to obtain property listed in Order No. 6 above. ____ G 8. THE COURT PROHIBITS EITHER PARTY from transferring, encumbering, or otherwise disposing of property jointly owned or leased, except in the normal course of business or that which is necessary for the support of the petitioner and/or the minor child(ren). ____ G 9. THE DEFENDANT IS ORDERED NOT TO damage any belongings of the protected person(s), not to shut off any utilities, telephone service, or mail delivery to the protected person(s) or in any way interfere with the living conditions of the protected person(s). ____ G10. THE COURT GRANTS TEMPORARY CUSTODY of the following child(ren) or alleged incompetent to the petitioner: (name, date of birth, and relationship to petitioner) ____ G11. THE COURT ORDERS a representative of _______________________ (law enforcement agency) to accompany petitioner to where the minor child(ren) or alleged incompetent mentioned in paragraph above is/are currently, and to effect petitioner obtaining physical custody of said child(ren) or alleged incompetent. ____ G12. THE DEFENDANT IS ORDERED NOT TO interfere with the physical custody of the minor child(ren) or alleged incompetent. LPOR 1 Page 3 of 5 v.5.1 Docket No. ________________ ____ G13. THE COURT WILL allow ___________________________________ to return to the residence at a date and time to be agreed upon by petitioner and law enforcement agency to recover his/her personal clothing and necessities, provided that s/he is accompanied by a law enforcement officer to ensure the protection and safety of the parties. NO FORCED ENTRY ALLOWED. ____ G14. THE COURT ORDERS a representative of ______________________________ (law enforcement agency) to accompany _____________________________ to the residence located at _____________________ to recover her/his personal clothing and necessities. ____ G15. THE COURT ORDERS THE DEFENDANT to show cause on the below hearing date why s/he should not be ordered to pay child support and/or spousal support (alimony) pursuant to Louisiana Law. The court further orders the defendant to produce at the hearing: most recent income tax returns, AND pay stubs or an employer statement documenting gross income to date for the CURRENT year. If the defendant is self-employed, income and expense statements shall be produced. ____ G16. THE COURT ORDERS THE DEFENDANT to show cause on the below hearing date why s/he should not be ordered to pay the following: G all court costs G attorney fees G evaluation fees G expert witness fees G cost of medical and/or psychological care for the petitioner, the minor child(ren), and/or alleged incompetent, necessitated by the domestic violence ____ G17. THE COURT ORDERS THE DEFENDANT to show cause on the below hearing date why s/he should not be ordered to seek professional counseling. ____ G18. THE COURT ORDERS THE DEFENDANT to show cause on the below hearing date why s/he should not be evicted from the solely owned residence or household and the petitioner granted possession. ____ G19. Other: ___ G IT IS FURTHER ORDERED that defendant show cause on the , 200 , at o’clock ___. M. in Courtroom No. Court, located at day of of the , in , La., why above Temporary Restraining Order and other relief requested should not be made Protective Orders. Date of Order Time of Order Expiration Date of Order ___/____/____ _________ ___/____/____ mo./ day /yr. GAM GPM mo./ day /yr. ___________________________________ SIGNATURE OF JUDGE ___________________________________ PRINT OR STAMP JUDGE’S NAME LPOR 1 Page 4 of 5 v.5.1 Docket No. ________________ NOTICE: C.C.P. Art. 3603.1 - Any person against whom such an order is issued shall be entitled to a court-appointed attorney if the applicant has likewise been afforded a court-appointed attorney. NOTICE TO DEFENDANT: PURSUANT TO LA. R.S. 14:79, A PERSON WHO VIOLATES THIS ORDER MAY BE ARRESTED, JAILED, AND PROSECUTED. PURSUANT TO LA. R.S. 46:2137 AND LA. CH. C. ART. 1571, A PERSON WHO VIOLATES THIS ORDER MAY BE PUNISHED FOR CONTEMPT OF COURT BY A FINE OF NOT MORE THAN $500 OR BY CONFINEMENT IN JAIL FOR AS LONG AS 6 MONTHS, OR BOTH, AND MAY BE FURTHER PUNISHED UNDER CRIMINAL LAWS OF THE STATE OF LOUISIANA. THIS ORDER SHALL BE ENFORCED BY ALL LAW ENFORCEMENT OFFICERS AND COURTS OF THE STATE OF LOUISIANA. _____________________________________________________ PURSUANT TO 18 U.S.C. § 922 [g][8], AFTER NOTICE AND OPPORTUNITY FOR A HEARING, THE DEFENDANT IN A PROTECTIVE ORDER THAT EITHER INCLUDES A FINDING BY THE JUDGE OR BY ITS TERMS EXPLICITLY PROHIBITS CERTAIN BEHAVIOR MAY BE PROHIBITED FROM RECEIVING, POSSESSING, OR TRANSPORTING FIREARMS OR AMMUNITION FOR THE DURATION OF THE ORDER IF THE PROTECTED PERSON(S) IS RELATED TO THE DEFENDANT AS A CURRENT OR FORMER SPOUSE, CURRENT OR FORMER COHABITING INTIMATE PARTNER, HAS A CHILD IN COMMON WITH THE DEFENDANT, OR IS THE CHILD OF DEFENDANT’S CURRENT OR FORMER INTIMATE PARTNER. FULL FAITH AND CREDIT pursuant to 18 U.S.C. § 2265 The issuing court certifies that it had jurisdiction over the parties and the subject matter under the laws of the State of Louisiana, and although the order was issued ex parte, the court has ordered that the defendant be given reasonable notice and an opportunity to be heard within the time required by the laws of the State of Louisiana. THIS ORDER SHALL BE PRESUMED TO BE VALID AND ENFORCEABLE IN ALL 50 STATES, THE DISTRICT OF COLUMBIA, TRIBAL LANDS, U.S. TERRITORIES, AND COMMONWEALTHS. SIGNATURE OF JUDGE G DEFENDANT WAS SERVED AT CLOSE OF HEARING. Date ________________________ G FAXED G MAILED Clerk _______________________________ TO LOUISIANA PROTECTIVE ORDER REGISTRY Date _________________________ Clerk _______________________________ Copies to: 1) Court file 2) Petitioner 3) Defendant 4) Chief Law Enforcement Official of the parish where the protected person resides 5) Louisiana Protective Order Registry. LPOR 1 Page 5 of 5 v.5.1 LOUISIANA UNIFORM ABUSE PREVENTION ORDER Case No. Order of Protection G G G Court:___________________________________ City/Parish T.R.O. P.O./Preliminary or Permanent Injunction Modified P.O./Preliminary or Permanent Injunction Louisiana PETITIONER First State PETITIONER IDENTIFIERS Middle/Maiden Last Petitioner seeks protection for: G self Date of Birth G other(s) List other(s) name & date of birth: __________________________________________ __________________________________________ ____________________________________________ ____________________________________________ V. DEFENDANT DEFENDANT IDENTIFIERS SEX First Middle RACE DOB HT WT EYES HAIR SOCIAL SECURITY # Last Relationship of Protected Person(s) to Defendant: (check all that apply) G current or former spouse G current or former unmarried intimate cohabitant G child, stepchild, or foster child G child of defendant’s current or former intimate partner G current or former dating partner G parent, stepparent, or foster parent G grandparent or grandchild G other: ______________________________________ DRIVERS LICENSE # STATE EXP DATE Defendant’s Address: _____________________________________ _____________________________________ THE COURT HEREBY FINDS: That it has jurisdiction over the parties and subject matter, and the defendant has been or will be provided with reasonable notice and opportunity to be heard. Additional findings of this court are as set forth below. THE COURT HEREBY ORDERS: That the above named defendant be restrained from committing further acts of abuse or threats of abuse. Additional terms of this order are as set forth on the following pages. The terms of this order shall be effective until (mm/dd/yy). WARNINGS TO DEFENDANT: This order shall be enforced, even without registration, by the courts of any state, the District of Columbia, any U.S. Territory, and may be enforced by Tribal Lands (18 U.S.C. Section 2265). Crossing state, territorial, or tribal boundaries to violate this order may result in federal imprisonment (18 U.S.C. Section 2262). Federal law provides penalties for possessing, transporting, shipping, or receiving any firearm or ammunition (18 U.S.C. Section 922(g)(8)). See further notice on last page of this order. Only the court can change this order. Page 1 of 5 LPOR 3 v.5.1 LOUISIANA UNIFORM ABUSE PREVENTION ORDER DIVISION: ____________ Pursuant to: DOCKET NO.__________ FILED: _______________ COURT NAME AND PARISH/CITY: CLERK:_______________ PROTECTIVE ORDER G La. R. S. 46:2131, et seq. G La. R.S. 46:2151 G La. Ch. C. Art. 1564, et seq. G Court Approved Consent Agreement PETITIONER’S NAME: ___________________________________________________ First Maiden/Middle Sex: G F Date of Birth ______/______/______ mo./ day / yr. Last GM Race: _____________ G On behalf of (name, date of birth, and relationship to petitioner) ___________________ __________________________________________________________________________ V. DEFENDANT’S NAME: ____________________________________________________ Alias:______________ Date of Birth: ___/____/____ mo./ day / yr. Sex: G F G M Race:_____ Address:___________________________________________________________________ No. & Street Apt. No. City State Zip Code Social Security #: _________________ Dr. Lic. #_______________ State ____ Exp. ___/___/___ The protected person(s) is related to the defendant as: (check all that apply) G current or former spouse G current or former unmarried intimate cohabitant G child, stepchild, or foster child G child of defendant’s current or former intimate partner G current or former dating partner G parent, stepparent, or foster parent G grandparent or grandchild G other: ______________________ G The protected person and the defendant have a child(ren) in common. IT IS ORDERED THAT THE DEFENDANT BE SERVED WITH A COPY OF THIS ORDER. THIS ORDER WAS ISSUED AFTER A HEARING, OF WHICH THE DEFENDANT HAD ACTUAL NOTICE AND AN OPPORTUNITY TO PARTICIPATE. THE COURT FINDS THAT THE ALLEGATIONS PRESENTED CONSTITUTE AN IMMEDIATE AND PRESENT DANGER OF ABUSE, THAT THE PETITIONER HAS GOOD AND REASONABLE GROUNDS TO FEAR FOR HER/HIS SAFETY OR THAT OF A CHILD OR ALLEGED INCOMPETENT, THUS THE COURT ISSUES THE FOLLOWING ORDERS: (only orders checked and initialed shall apply) ____ G 1. THE DEFENDANT IS ORDERED NOT TO abuse, harass, stalk, follow, or threaten the protected person(s) in any manner whatsoever. This prohibition includes the use, attempted use, or threatened use of force or physical violence that would reasonably be expected to cause bodily injury. ____ G 2. THE DEFENDANT IS ORDERED NOT TO contact the protected person(s) personally, electronically, by phone, in writing, or through a third party, without the express written permission of this court. ____ G 3. THE DEFENDANT IS ORDERED NOT TO go within one hundred (100) yards of the residence, apartment complex, or multiple family dwelling of the protected person(s) located at: _________________________________________________________________ No. & Street Apt. No. Page 2 of 5 City State Zip Code LPOR 3 v.5.1 Docket No. _______________ ____ G 4. THE DEFENDANT IS ORDERED TO STAY AWAY from the protected person(s)’ place of employment/school and not to interfere in any manner with such employment/school located at: _________________________________________________________________________ Employment/School Address City State Zip Code _________________________________________________________________________ Employment/School ____ Address City State Zip Code G 5. THE COURT GRANTS THE PETITIONER or protected person(s) the use of the residence located at: _________________________________________________________________________ No. & Street Apt. No. City State Zip Code to the exclusion of defendant by evicting defendant. The Court orders the defendant to surrender any keys to that residence to the petitioner. ______________________________ (law enforcement agency) is ordered to evict the defendant. ____ G 6. THE COURT GRANTS THE PETITIONER or protected person(s) the use and possession of the following property: ____ G 7. THE COURT ORDERS a representative of _______________________________ (law enforcement agency) to accompany petitioner to obtain property listed in Order No. 6 above. ____ G 8. THE COURT PROHIBITS EITHER PARTY from transferring, encumbering, or other- wise disposing of property jointly owned or leased, except in the normal course of business or that which is necessary for the support of the petitioner and/or the minor child(ren). ____ G 9. THE DEFENDANT IS ORDERED NOT TO damage any belongings of the protected person(s), not to shut off any utilities, telephone service, or mail delivery to the protected person(s), or in any way interfere with the living conditions of the protected person(s). ____ G 10. THE COURT GRANTS TEMPORARY CUSTODY of the following child(ren) or alleged incompetent to the petitioner: (name, date of birth, and relationship to petitioner) ____ G 11. THE COURT ORDERS a representative of _______________________ (law enforcement agency) to accompany petitioner to where the minor child(ren) or alleged incompetent mentioned in paragraph above is/are currently, and to effect petitioner obtaining physical custody of said child(ren) or alleged incompetent. ____ G 12. THE COURT GRANTS defendant visitation with the minor child(ren) or alleged incompetent as follows: Exchange of child(ren) or alleged incompetent is to be effected as follows: _____________ _________________________________________________________________________ Page 3 of 5 LPOR 3 v.5.1 Docket No. _______________ ____ G 13. THE DEFENDANT IS ORDERED NOT TO interfere with the physical custody of the minor child(ren) or alleged incompetent. ____ G 14. THE COURT WILL allow ___________________________________ to return to the residence at a date and time to be agreed upon by petitioner and law enforcement agency to recover his/her personal clothing and necessities, provided that s/he is accompanied by a law enforcement officer to ensure the protection and safety of the parties. NO FORCED ENTRY ALLOWED. ____ G 15. THE COURT ORDERS a representative of _______________________ (law enforcement agency) to accompany ___________________________ to the residence located at __________________________ to recover her/his personal clothing and necessities. ____ G 16. THE COURT ORDERS THE DEFENDANT TO PAY SUPPORT for G the petitioner at the rate of $______________ per G week G month beginning _____________________, 200___, G the child(ren) at the rate of $______________ per G week G month beginning _____________________, 200___, G directly to the petitioner G other: ______________________________________________________________ ____ G 17. THE COURT ORDERS THE DEFENDANT to pay: G all court costs G attorney fees G expert witness fees G evaluation fees G cost of medical and/or psychological care for the petitioner, the minor child(ren), and/or the alleged incompetent, necessitated by the domestic violence ____ G 18. THE COURT ORDERS THE DEFENDANT to seek professional counseling. ____ G 19. Other: Date of Order Expiration Date of Order _______________________________ SIGNATURE OF JUDGE ___/____/____ mo./ day /yr. ___/____/____ mo./ day /yr. _______________________________ PRINT OR STAMP JUDGE’S NAME NOTICE: C.C.P. Art. 3603.1 - Any person against whom such an order is issued shall be entitled to a court-appointed attorney if the applicant has likewise been afforded a court-appointed attorney. Page 4 of 5 LPOR 3 v.5.1 Docket No. _______________ NOTICE TO DEFENDANT: PURSUANT TO LA. R.S. 14:79, A PERSON WHO VIOLATES THIS ORDER MAY BE ARRESTED, JAILED, AND PROSECUTED. PURSUANT TO LA. R.S. 46:2137 AND LA. CH. C. ART. 1571, A PERSON WHO VIOLATES THIS ORDER MAY BE PUNISHED FOR CONTEMPT OF COURT BY A FINE OF NOT MORE THAN $500 OR BY CONFINEMENT IN JAIL FOR AS LONG AS 6 MONTHS, OR BOTH, AND MAY BE FURTHER PUNISHED UNDER CRIMINAL LAWS OF THE STATE OF LOUISIANA. THIS ORDER SHALL BE ENFORCED BY ALL LAW ENFORCEMENT OFFICERS AND COURTS OF THE STATE OF LOUISIANA. _____________________________________________________ PURSUANT TO 18 U.S.C. § 922 [g][8], THE DEFENDANT IN A PROTECTIVE ORDER THAT EITHER INCLUDES A FINDING BY THE JUDGE OR BY ITS TERMS EXPLICITLY PROHIBITS CERTAIN BEHAVIOR IS PROHIBITED FROM RECEIVING, POSSESSING, OR TRANSPORTING FIREARMS OR AMMUNITION FOR THE DURATION OF THE ORDER IF THE PROTECTED PERSON(S) IS RELATED TO THE DEFENDANT AS A CURRENT OR FORMER SPOUSE, CURRENT OR FORMER COHABITING INTIMATE PARTNER, HAS A CHILD IN COMMON WITH THE DEFENDANT, OR IS THE CHILD OF DEFENDANT’S CURRENT OR FORMER INTIMATE PARTNER. FULL FAITH AND CREDIT pursuant to 18 U.S.C. § 2265 The issuing court certifies that it had jurisdiction over the parties and the subject matter under the laws of the State of Louisiana, and the defendant was given reasonable notice and opportunity to be heard sufficient to protect the defendant’s right to due process before this order was issued. THIS ORDER SHALL BE PRESUMED TO BE VALID AND ENFORCEABLE IN ALL 50 STATES, THE DISTRICT OF COLUMBIA, TRIBAL LANDS, U.S. TERRITORIES, AND COMMONWEALTHS. SIGNATURE OF JUDGE PETITIONER DEFENDANT G DEFENDANT WAS SERVED AT CLOSE OF HEARING. Date _________________________ G FAXED G MAILED Clerk _______________________________ TO LOUISIANA PROTECTIVE ORDER REGISTRY Date _________________________ Clerk _______________________________ Copies to: 1) Court file 2) Petitioner 3) Defendant 4) Chief Law Enforcement Official of the parish where the protected person resides 5) Louisiana Protective Order Registry. Page 5 of 5 LPOR 3 v.5.1