Judge Time Hours Minutes CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR City/County Located at MD Court Address Telephone No. Case No. TEMPORARY PROTECTIVE 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 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. Additional terms of the Order are as set forth in this document. The terms of this Order shall be effective until Only the Court can change this Order. Month/Day/Year 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. 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. www.FormsWorkFlow.com Page 1 of 5 CC-DC/DV 2 (Rev. 10/2010) 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: A. That Respondent's Counsel, and in , 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 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 That the Respondent consents to the entry of a protective order without a finding of abuse. C. OR That there are reasonable grounds to believe that the Respondent committed the following abuse(s): 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) (Forward to DSS for investigation.) Statutory abuse of a vulnerable adult on at Date Time Description of Harm AND That there are reasonable grounds to believe that the above abuse(s) consisted of the use of a firearm, a threat to use a firearm by the Respondent, serious bodily harm, or a threat of serious bodily harm to person or persons eligible for relief. Weapon(s) involved, type . That the Respondent has access to firearm(s). D. 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 2 (Rev. 10/2010) Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Date Case No. Based on the foregoing, the Court hereby ORDERS: 1. That the Respondent SHALL NOT abuse, threaten to abuse, and/or harass 2. That the Respondent SHALL NOT contact (in person, by telephone, in writing, or by any other means) or attempt to contact 3. That the Respondent SHALL NOT enter the residence of at (Residence includes yard, grounds, outbuildings, and common areas surrounding the dwelling.) An undisclosed location for reasons of safety. 4. Respondent SHALL STAY AWAY from: (1) School: (2) School: (3) School: An undisclosed school for reasons of safety. (1) Childcare provider at while (2) Childcare provider at while An undisclosed childcare provider for reasons of safety. is in the care of the childcare provider. 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. 5. That the Respondent SHALL VACATE the home immediately (home includes yard, grounds, outbuildings, and common areas surrounding the dwelling) at and remain away until the hearing provided for below. (Paragraph 7 and hearing date set on extension of order.) Temporary 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. CC-DC/DV 2 (Rev. 10/2010) Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Date Case No. Custody of is awarded to until the hearing provided for in Paragraph 8 below. Custody shall remain joint. 6. 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. 7. 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 Order. 8. THAT A FINAL PROTECTIVE ORDER HEARING SHALL BE HELD ON , AT A.M./P.M. AT Court Address 9. This Order supersedes and overrides any previously entered Interim Protective Order issued by a Commissioner. Date Judge Time Print Name This Order is extended for not more than 6 months until: New Hearing Date Judge Date New Hearing Date Judge Date New Hearing Date Judge Date NOTICE TO RESPONDENT A Petition for Protection alleges that you have committed abuse. On the basis of the Petition this Temporary Protective Order has been issued. Violation of this Order may be a state and/or federal crime or contempt of court, or both, and result in imprisonment or fine or both. This Order may be enforced by another state or jurisdiction, which may impose additional or different penalties for the violation. In order to respond to the allegation that abuse occurred, you must appear in court at the Final Protective Order hearing provided for in this Order. If at the hearing the court finds by clear and convincing evidence that abuse occurred, the court will issue a Final Protective Order against you, whether you appear or fail to appear, and may order all or part of the relief requested by the Petitioner or granted in this Order. This relief may include: temporary use and possession of your home, use and possession of jointly owned vehicles, Emergency Family Maintenance, child visitation, surrender of firearm(s) to a law enforcement agency, and counseling or participation in a domestic violence program. A Final Protective Order may be in effect: (a) for as long as one (1) year, and the court for good cause may extend the term of the Final Protective Order for an additional six (6) months after a further hearing; or (b) a Final Protective Order may be extended for a period not to exceed two (2) years, if a judge finds the respondent has committed a subsequent act of abuse against the petitioner or a protected person; or (c) a Final Protective Order may last for as long as two (2) years, if there is a finding that this is a subsequent act of abuse 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, and the prior Final Protective Order was issued for a period of at least six (6) months. If you fail to appear in court and a Final Protective Order is issued, you will be served by first-class mail at your last known address with the Final Protective Order and all other notices concerning the Protective Order. The Final Protective Order will be valid and enforceable upon mailing. It is your responsibility to notify the court in writing of any change of address. State law requires the Respondent to surrender all firearms to a law enforcement agency if a Final Protective Order is issued. CC-DC/DV 2 (Rev. 10/2010) Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Case No. -------------------------------------------------------------------------------- Date -------------------------------------------------- NOTICE TO ALL PARTIES Each party may be represented by an attorney. At the Final Protective Order hearing, the petitioner will be required to prove the alleged facts by clear and convincing evidence. This is difficult to do if you do not have legal training. Each party should see a lawyer. If you are the petitioner and cannot get a private lawyer, there are support agencies that may be able to help you. Although each party is not required to have a lawyer at the hearing, all of the Rules of Evidence will apply to the case. If you choose not to have a lawyer with you on the hearing date, the Petitioner will still have to prove the case by "clear and convincing evidence" and each party will have to comply with the Rules of Evidence. Due to the emergency nature of the hearing, the hearing may be held even if a party requests more time to obtain an attorney. At the Final Protective Order hearing, the court may order the Respondent to pay Emergency Family Maintenance and may pass an immediate and continuing withholding order for that purpose. If Emergency Family Maintenance is requested, both parties should complete a Financial Statement (CC-DC/DV 4) before the Protective Order hearing and bring it to court. You should also bring documents (such as pay stubs, copy of your lease, bills, etc.) to support the figures you supply. TRUE COPY CERTIFICATION OF TEMPORARY 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 --------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------- Clerk Attestation of Judge I, ---------------------------------------------------------------------------------------- , Judge of the Court in --------------------------------------------------------------------------------------------- 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 --------------------------------------------------------------------------- City/County and that his/her attestation is in due form of law. ---------------------------------------------------------------------------------------- Date Court: -------------------------------------------------------------------------------------------------------------------------------------- Judge ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 2 (Rev. 10/2010) Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com