Judge Time Hours Minutes CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR City/County Located at MD Court Address Telephone No. Case No. FINAL PROTECTIVE ORDER Amended Order PETITIONER/PLAINTIFF First Middle Last Date of Birth and any minor(s) or minor child(ren) on whose behalf the petition was filed. (List names and date(s) of birth.) OTHER(S) TO BE PROTECTED: Name DOB Name DOB Name DOB Name DOB Name DOB Name DOB VS. RESPONDENT/DEFENDANT RESPONDENT IDENTIFIERS SEX Relationship to Petitioner Spouse Vulnerable adult Former Spouse Children in Common Cohabitant Parent Other relationship EYES HAIR DOB City, State, Zip HT WT DISTINGUISHING FEATURES DRIVER'S LICENSE # Address CAUTION: RACE STATE EXPIRES Telephone Weapon Involved Type Access to Firearm(s) VEHICLE DESCRIPTION TAG NO. EMPLOYER THE COURT FINDS that under the laws of Maryland the issuing Court has jurisdiction over the parties and the subject matter. The Respondent was given reasonable notice and an opportunity to be heard at a Protective Order Hearing. THE COURT ORDERS: That the above named Respondent SHALL NOT abuse, threaten to abuse, and/or harass the Protected Parties. That the above named Respondent SHALL NOT contact the Protected Parties by any means, except as stated in this Order. Additional terms of the Order are as set forth in this document. The terms of this Order shall be effective until Month/Day/Year Only the Court can change this Order. NOTICE TO RESPONDENT: PENALTIES Violation of this Order may result in criminal prosecution, imprisonment and/or fine, and contempt of court. Law enforcement shall arrest a person whom the officer has probable cause to believe is in violation of this Order, as required by Maryland Code, Family Law Article, § 4-508 and Criminal Procedure §2-204.1. In accordance with Maryland Code, Family Law Article § 4-506(f), no respondent against whom a current final civil protective order has been entered may possess any firearm. This Protective Order shall be recognized and enforced by the courts of any state, the District of Columbia, any U.S. Territory, tribal lands (18 U.S.C. § 2265) or Department of Defense installations. (10 U.S.C. § 1561a) Crossing state, territorial, or tribal boundaries to violate this Order may result in federal imprisonment. (18 U.S.C. § 2262) Federal law provides penalties of up to $250,000 fine and 10 years in prison for possessing, transporting, shipping, or receiving any firearm or ammunition while subject to a protective order or after being convicted of a misdemeanor crime of domestic violence (18 U.S.C. § 922(g)(8)) or knowingly transferring a firearm after a conviction of a misdemeanor crime of domestic violence (18 U.S.C. § 922(g)(9)). Questions regarding this notice should be directed to your attorney, law enforcement agency, or the Maryland State Police Firearms Enforcement Section at 410-290-0050. American LegalNet, Inc. CC-DC/DV 3 (Rev. 10/2010) Page 1 of 5 www.FormsWorkFlow.com Date Case No. After the appearance of the Petitioner Petitioner's Counsel Respondent consideration of the Petition and evidence, the Court makes the following findings: Respondent's Counsel, and in I. Original Request A. That , who is a Person(s) Eligible for Relief, is: The current spouse of the Respondent. A former spouse of the Respondent. A cohabitant with the Respondent. An individual related to the Respondent by blood, marriage, or adoption Relationship A parent, stepparent, child or stepchild of the Respondent or a Person Eligible for Relief who resides or resided with the Respondent or Person(s) Eligible for Relief for at least 90 days within one year before the filing of the Petition. A vulnerable adult. An individual who has a child(ren) in common with the Respondent Number of Children and Ages Eligible for extended protection: A Final Protective Order was issued against the respondent on behalf of this Petitioner. The act of abuse was committed within one (1) year after the date that a prior Final Protective Order issued against the same Respondent on behalf of the same person eligible for relief expires. The prior Final Protective Order was issued for a period of at least six (6) months. B. That the Petitioner is: The person Eligible for Relief. In the case of a vulnerable adult or minor child: A State's Attorney A local department of social services A relative An adult residing in the home C. That the Respondent consents to the entry of a protective order without a finding of abuse. OR There is clear and convincing evidence to believe that the Respondent committed the following act(s) of abuse: Caused serious bodily harm Placed Person Eligible for Relief in fear of imminent serious bodily harm Assault in any degree Rape or a statutory sexual offense (or attempt) in any degree False Imprisonment Stalking Statutory abuse of a child ( Physical Sexual Mental) Statutory abuse of a vulnerable adult on at . . . Date D. Time Description of Harm That the Respondent has access to firearm(s). E. That, in the case of a request for an order to vacate the home, the Respondent and Person(s) Eligible for Relief resided together at the time of abuse and: Are married, or Are not married, but The name of a Person Eligible for Relief is on the lease or deed. A Person Eligible for Relief has resided in the home with the Respondent for at least 90 days within the past year. In the case of abuse of a child or vulnerable adult, an adult other that the Respondent lives in the home. CC-DC/DV 3 (Rev. 10/2010) Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Case No. F. ----------------------------------------------------------------------------------- Date ----------------------------------------------------- The Parties have agreed to waive the Temporary Protective Order hearing. II. Permanent Protection Request (Note: Relief is restricted to that which is provided in § 4-506 (d)(1) and (d)(2) Paragraph 2 and 3 as described below): That in Case No. , under this statute, this Petitioner was a victim of the abuse and a person(s) eligible for relief and Respondent was the Respondent. Respondent was convicted and served a term of imprisonment of at least five years under § 2-205, § 2-206, § 3-202, § 3-303, § 3-304, § 3-305, § 3-306, § 3-309, § 3-310, § 3-311, or § 3-312 of the Criminal Law Article for the act of abuse that led to the issuance of the original Final Protection Order. III. Request for Extension not to exceed two (2) years. This Petitioner or a protected person was a victim of a subsequent act of abuse during the active period of this order of protection. Based on the foregoing, the Court hereby ORDERS: 1. That unless stated otherwise below, this Order is effective until 2. That the Respondent SHALL NOT abuse, threaten to abuse, and/or harass 3. That the Respondent SHALL NOT contact (in person, by telephone, in writing, or by any other means) or attempt to contact except to facilitate any child visitation ordered in #8 below. . . That the Respondent SHALL NOT enter the residence of 4 at (Residence includes yard, grounds, outbuildings, and common areas surrounding the dwelling.) An undisclosed location for reasons of safety. 5. Respondent SHALL STAY AWAY from: (1) School: (2) School: (3) School: An undisclosed school for reasons of safety. (1) Childcare provider at while is in the care of the childcare provider. (2) Childcare provider at while An undisclosed childcare provider for reasons of safety. is in the care of the childcare provider. (1) Place of employment: (2) Place of employment: An undisclosed place of employment provider for reasons of safety. (1) Temporary residence of at (2) Temporary residence of at An undisclosed temporary residence for reasons of safety. (1) The home of another family member at (2) The home of another family member at An undisclosed home of another family member for reasons of safety. CC-DC/DV 3 (Rev. 10/2010) Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Case No. ------------------------------------------------------------------------------------- Date --------------------------------------------------6. That the Respondent SHALL VACATE the home immediately (home includes yard, grounds, outbuildings, and common areas surrounding the dwelling) at and remain away. In the meantime, use and possession of the home is granted to The Respondent, accompanied by a law enforcement officer, may return to collect clothing and personal necessities, only between the hours of and on or Time Time Date as directed by local law enforcement. 7. 8. Custody of is awarded to Custody of is awarded to Custody shall remain as set forth in The children) shall primarily reside with Case Number Custody shall remain joint. Law enforcement officers are ordered to use all reasonable and necessary force to return the minor child(ren) to the custodial parent after service of this Order. Visitation with Name(s) of Child(ren) is granted to every other weekend from every from (time of day) until Name(s) to ; (day) (time of day); The following additional visitation terms also apply (eg. transportation, exchange location, name of visitation coordinator, etc.): Visitation shall be supervised by 9. That the Respondent SHALL PAY Emergency Family Maintenance in the amount of every week 2 weeks month to beginning (Date) and mail payment to the following address: (Name) (Name) Emergency Family Maintenance shall be paid by way of an Earnings Withholding Order. 10. That exclusive use and possession of the vehicle described as is granted to 11. That the Respondent SHALL participate in and meet the requirements of the following domestic violence and/or other professionally supervised counseling program(s): That the Petitioner SHALL participate in and meet the requirements of the following domestic violence and/or other professionally supervised counseling program(s): X That the Child(ren) SHALL participate in and meet the requirements of the following domestic violence and/or other professionally supervised counseling program(s): 12. That the Respondent SHALL immediately surrender all firearm(s) to law enforcement agency , and to refrain from possession of any firearm, for the duration of this Protective Order. Page 4 of 5 CC-DC/DV 3 (Rev. 10/2010) American LegalNet, Inc. www.FormsWorkFlow.com Case No. ------------------------------------------------------------------------------------ Date ------------------------------------------------- 13. That the Respondent SHALL pay costs, including costs for out-of-state service. 14. This Order supersedes and overrides any previously entered Final Protective Order. 15. Additional Conditions: ---------------------------------------------------------------------------------------------------------------------------------------- Judge Date Printed Name Each party shall be served with a copy of this Final Protective Order. The clerk shall mail additional copies to the following: 1. 3. 2. 4. CERTIFICATION OF ISSUING JUDGE It is certified under the laws of Maryland: (1) The issuing court has jurisdiction over the parties and the subject matter. (2) The Respondent was given reasonable notice and an opportunity to be heard at a Protective Order hearing. (3) In the case where mutual Protective Orders have been issued, the court has made a detailed finding of fact that each party was entitled to such an order. ----------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- Date Judge Court: -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Address: -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Phone: -------------------------------------------------------------------------------------------------------------- Fax: ---------------------------------------------------------------------------------------------------------- TRUE COPY CERTIFICATION OF FINAL PROTECTIVE ORDER Attestation of Clerk I, -------------------------------------------------------------------------------------- , Clerk of the Court in --------------------------------------------------------------------------------------------City/County, State of Maryland, do hereby certify that I have compared this Order with the original Order, which is on file in my office, and that this Order is a true and correct copy of the original, and the whole thereof. In testimony whereof, I have hereunto set my hand and affixed the seal of said Court at Maryland, this ---------------------------------------------------------------------------------------------- ------------------------------ day of ---------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------- Attestation of Judge I, ---------------------------------------------------------------------------------------- , Judge of the Court in Clerk --------------------------------------------------------------------------------------------- City/County, State of Maryland, do hereby certify that --------------------------------------------------------------------------------------------------------- , whose name is subscribed to the foregoing certificate of attestation, now is, and/or was at the time of signing and sealing the same, a Clerk of this Court in ------------------------------------------------------------------------- ------------------------------------------------------------------------------------------- Date City/County and that his/her attestation is in due form of law. ------------------------------------------------------------------------------------------------------------------ Judge Court: --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Address: --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Phone:-------------------------------------------------------------------------------------------------- Fax: ----------------------------------------------------------------------------------------------------------------------To request a foreign language interpreter or a reasonable accommodation under the Americans with Disabilities Act, please contact the court immediately. CC-DC/DV 3 (Rev. 10/2010) Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com