3.(If the victim is a child or vulnerable adult, fill in the following): I am asking for protection for a childvulnerable adult whose name isAt this time the victim can be found atI am State's Attorney DSS a relative an adult living in the home.4.The person(s) I want protected are (include yourself if you are a victim):Names(s)BirthdateRelationship to Respondent CIRCUIT COURT DISTRICT COURT OF MARYLAND FORLocated atCase No.Court AddressCity/County(NOTE: Fill in the following, checking the appropriate boxes. Petitioners need not give an address if doing so risksfurther abuse or reveals the confidential address of a shelter. If this is the case, check here If you need additionalpaper, ask the clerk.)PetitionerStreet Address, Apt. No.Telephone Number(s)City, State, ZipHome:Work:vs.RespondentStreet Address, Apt. No.Telephone Number(s)City, State, ZipHome:Work:PETITION FOR PROTECTION FROM DOMESTIC VIOLENCE CHILD ABUSE VULNERABLE ADULT ABUSE(Family Law 247 4-504)1. I am: the current or former spouse of the respondent; a cohabitant of the respondent; a person related tothe respondent by blood, marriage, or adoption; a parent, stepparent, child, or stepchild of the respondent or theperson eligible for relief who resides or resided with the respondent or person eligible for relief for at least 90 dayswithin 1 year before the filing of the petition; a vulnerable adult; an individual who has a child in common withthe respondent; or an individual who has had a sexual relationship with the Respondent within one (1) year beforethe filing of the Petition.2. I want relief for myself minor child vulnerable adult, from abuse byThe Respondent, whose present whereabouts (if known) are,committed the following acts of abuse againstDateName of alleged abuseron or about, (check all that apply.)(Give specific details of what happened, when and where it happened, and any injuries sustained):Page 1 of 3CC-DC-DV-001 (Rev. 10/2018) other kicking punching choking/stranglingslapping shooting rape or other sexual offense (or attempt) hitting with object stabbing shovingthreats of violence mental injury of a child detaining against will stalking biting revenge porn American LegalNet, Inc. www.FormsWorkFlow.com 5. The person(s) I want protected now lives, or has lived, with the Respondent for the following period of time duringthe past year:There are are not additional persons living in the home.6. I know of the following court cases involving me, or the person I want protected, and the Respondent. (Examplesinclude: paternity, child support, divorce, custody, domestic violence, juvenile cases, criminal cases)CourtKind of CaseYear FiledResult or Status (if you know)8. Describe all past injuries the Respondent has caused the victim, and give date, if known9. The Respondent owns or has access to the following firearms:10. I want the court to order the Respondent: (NOTE: Petitioner need not give an address if doing so risks further abuse.)NOT to abuse or threaten to abuseName(s)NOT to contact, attempt to contact, or harassName(s)NOT to go to the residence(s) atAddressNOT to go to the school(s) atName of school and addressNOT to go to the child care provider(s)Name of child care provider and addressNOT to go to the work place(s) atName(s)Page 2 of 3Case No.vs.PetitionerRespondentDate issuedLocation where issuedCity/County/StateDate expired7. I have received a final protective order against the same respondent that expired within one (1) year of the abusealleged in this petition, and which was issued for a period of at least six (6) months.CC-DC-DV-001 (Rev. 10/2018) American LegalNet, Inc. www.FormsWorkFlow.com 11. I also want the Court to order:Custody ofbe granted toUse and possession of the following jointly-owned vehicle be granted to12. (Fill in only if you are seeking Emergency Family Maintenance.) The Respondent has the following financial resources:Income from employment in the amount of $ every week 2 weeks monthI solemnly affirm under the penalties of perjury that the contents of the foregoing Petition are true to the best of myknowledge, information and belief.DateI have filled in the Addendum (Description of Respondent), CC-DC-DV-001ANOTEThe law enforcement officer must protect you from harm when responding to your request for assistance and may, if youask, accompany you to the family home so that you may remove clothing and medicine, medical devices, and otherpersonal effects required for you and your children, regardless of who paid for them.Page 3 of 3Children's namesNameDescription of vehicleName and address of source and amount(s) receivedName and address of source and amount(s) receivedEstimated ValueEstimated ValueEstimated ValueEstimated ValueNameYou are entitled to request that the address and telephone number of a victim, a complainant, or a witness be consideredfor shielding at the filing of this application.NOTICE: Remote access to the name, address, telephone number, date of birth, e-mail address, and place of employmentof a victim or non-party witness is subject to blocking in accordance with Md. Rule 16-910. A person who causesidentifying information relating to a witness to be placed in a judicial record shall give the clerk written or electronicnotice whether the information is not subject to remote access under Md. Rule 16-910.Case No.vs.PetitionerRespondentPetitionerTo turn over firearm(s) to a law enforcement agency.To go to counseling domestic violence drug/alcohol otherTo pay money as Emergency Family Maintenance (may be taken from Respondent's paycheck).To leave the home atAddressand give possession of the home toThe name(s) on the deed or lease are:If you believe that you have been a victim of abuse and that there is a danger of serious and immediate injury to you, youmay request the assistance of a police officer or local law enforcement agency.Temporary possession of the pet(s)NameName and Descriptionbe granted toCC-DC-DV-001 (Rev. 10/2018)In the final order, the following additional relief necessary to protectPerson Eligible for Relief otherSource of employment incomeIncome from other sourceThe Respondent also owns the following property of value: Automobile(s) $Home $ Bank Account(s) $Other:from abuse: American LegalNet, Inc. www.FormsWorkFlow.com