ORI No: Order No: NYSID No. Form SC -2 8/2010 At a ___________ Term (IAS Part) ______________ of the Supreme Court, State of New York, County of , at the Courthouse at PRESENT: Hon. In the M atter of a Proceeding under Section (240) (252) of the Domestic Relations Law Plaintiff/Petitioner Date of Birth: v. ORDER OF PROTECTION D.R.L. §§ 240, 252 Index No. (Check one) ❑ Upon Default ❑ Both Parties Present In Court Defendant/Respondent Date of Birth: NOTICE: YOUR FAILURE TO OBEY THIS ORDER M AY SUBJECT YOU TO M ANDATORY ARREST, AND CRIM INAL PROSECUTION, W HICH M AY RESULT IN YOUR INCARCERATION FOR UP TO SEVEN YEARS FOR CRIM INAL CONTEM PT, AND/OR M AY SUBJECT YOU TO SUPREM E COURT PROSECUTION AND PENALTIES FOR CONTEM PT OF COURT. Whereas a determination has been made in accordance with section ❑ 240 ❑ 252 of the Domestic Relations Law, and the Respondent having been [check applicable box]: ❑ present in Court and advised of the issuance and contents of this Order ❑ not present in Court, and good cause having been shown, Now, therefore, it is hereby ordered that [specify first name, middle initial and last name]: observe the following conditions of behavior: (Check Applicable Paragraphs and Subparagraphs) [01] ❑ Stay away from [A] ❑ [name(s) of protected person(s)] ___________________________________________, and/or from the [B]❑ home of _______________________________, [C] ❑ school of __________________________ , [D]❑ business of _____________________________, [E] ❑ place of employment of ________________________ , [F] ❑ other [specify location] ________________________ _____________________________________; [14] ❑ Refrain from communication or any other contact by mail, telephone, e-mail, voice-mail or other electronic or any other means with [specify protected person(s)]: [02] ; ❑ Refrain from assault, stalking, harassment, aggravated harassment, menacing, reckless endangerment, strangulation, criminal obstruction of breathing or circulation, disorderly conduct, criminal mischief, sexual abuse, sexual misconduct, forcible touching, intimidation, threats or any criminal offense against [specify protected person(s) and/or members of protected person’s family or household and/or person(s) with custody of child(ren)]: [15] ; ❑ Refrain from intentionally injuring or killing without justification the following companion animal(s) (pet(s)) [specify type(s) and, if available, name(s)]:____________________________________________________________________________ ; [11] ❏ Permit [specify individual]: __________________________________to enter the residence during [specify date/time]: __________________ with [specify law enforcement agency, if any]: ___________________ in order to remove personal belongings not in issue in litigation [specify items]: ; [04] ❏ Refrain from [indicate acts]: that create an unreasonable risk to the health, safety, or welfare of [specify child(ren), family or household members]: ; [05] ❏ Permit [specify individual]: separation or other written agreement, to visit with [specify child(ren]: during the following periods of time [specify]: under the following terms and conditions [specify]: , entitled by a court order, ; American LegalNet, Inc. www.FormsWorkFlow.com SC-2 Page 2 [07] ❏ Custody of [specify child(ren)]: [specify individual]: conditions [specify]: [12] ❏ Surrender any and all handguns, pistols, revolvers, rifles, shotguns and other firearms owned or possessed, including, but not limited to, the following [specify]: and do not obtain any further guns or other firearms. Such surrender shall take place immediately, but no later than [specify date/time]: at [specify]: ; ❏ shall be awarded to under the following terms and ; Pay or provide access to health or medical insurance for necessary medical care and treatment arising from the incident or incidents forming the basis of the order [specify beneficiary of treatment and coverage]: ; ❏ Pay counsel fees and/or any costs associated with the order to [specify person and terms] ; ❏ Participate in an educational program, (and pay the costs thereof)[(specify program] ; ❏ ❏ Participate in a batterer's education program designed to help end violent behavior (and pay the costs thereof)[specify program]: ; Pay to the petitioner/victim(s) restitution, as follows [specify terms and amount up to $10,000]: ; and [99] ❏ Observe such other conditions as are necessary to further the purposes of protection [specify conditions]: It is further ordered that the license of the person against whom this order is issued to carry, possess, repair, sell or otherwise dispose of a firearm or firearms, if any, pursuant to Penal Law §400.00, is hereby [13A] ❑ suspended or [13B] ❑revoked, (note: final order only) and/or [13C] ❑ the person against whom this order is issued shall remain ineligible to receive a firearm license during the period of this order. (Check all applicable boxes). It is further ordered that this order of protection shall remain in force until and including [specify date]: but if you fail to appear in court on this date, the order may be extended and continue in effect until a new date set by the Court. , The Domestic Relations Law provides that the presentation of a copy of this Order of Protection to a police officer or peace officer acting pursuant to his or her special duties shall authorize, and sometimes requires, such officer to arrest a person who is alleged to have violated the terms of the order and to bring him or her before the Court to face penalties authorized by law. Federal law requires that this order must be honored and enforced by state and tribal courts, including courts of a state, the District of Columbia, a commonwealth, territory or possession of the United States, if the person against whom the order is sought is an intimate partner of the protected party and has or will be afforded reasonable notice and opportunity to be heard in accordance with state law sufficient to protect that person's rights (18 U.S.C. §§ 2265, 2266). It is a federal crime to: • cross state lines to violate this order or to stalk, harass or commit domestic violence against an intimate partner or family member; • buy, possess or transfer a handgun, rifle, shotgun or other firearm or ammunition while this Order remains in effect (Note: there is a limited exception for military or law enforcement officers but only while they are on duty) ; and • buy, possess or transfer a handgun, rifle, shotgun or other firearm or ammunition after a conviction of a domestic violence-related crime involving the use or attempted use of physical force or a deadly weapon against an intimate partner or family member, even after this Order has expired.. (18 U.S.C. ''922(g)(8), 922(g)(9), 2261, 2261A, 2262). Dated: JUSTICE COURT (COURT SEAL) Check Applicable Box(es): ❏ Party against whom order was issued was advised in Court of issuance and contents of Order ❏ Order personally served in Court upon party against whom order was issued ❏ Service directed by other means [specify]: ❏ [Modifications or extensions only]: Order mailed on [specify date and to whom mailed]: ❏ W arrant issued for party against whom order was issued [specify date]: ❏ Additional service information [specify]: __________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com