City/CountyDISTRICT COURT OF MARYLAND....................................................................................................................... Located at ..................................................................................................... Case No. ........................................................... Court Address .................................................................................................. vs..................................................................................................... Petitioner Respondent PEACE ORDER SUPPLEMENT Dating Violence 1. Do you contend that YOU are (or were) in a dating relationship whe reby the respondent engaged in a course of conduct with the intent to kill, injure, intimidate, or harass you in a manner that placed you in a reasonable fear of death or physical harm? 9 9 Yes No Sexual Assault 2. Do you contend that the respondent engaged in a sexual assault against you and without your consent that placed you in fear of physical harm or danger? 9 9 Yes No Stalking 3. Do you contend that the respondent has engaged in a malicious course of conduct in which the respondent approached or pursued you with intent to place you in reasonable fear of serious bodily injury or death? 9 9 Yes No ................................................................................................... Signature of PetitionerPO 1S (Rev. 2/2003)