FCA §§154-d, 822; CPL §§530.12 (3),(3-a),(3-b) (Local Criminal Court): County of _________________________________ Family Court General Form 5c Criminal Form 4 12/2013 Petitioner on behalf of [specify]: AFFIDAVIT IN SUPPORT OF ISSUANCE OF FAMILY COURT TEMPORARY ORDER OF PROTECTION (By Peace or Police Officer, Agency or Designated Person) Index/Docket # -against-- Respondent _______________________________________ State of New York ) ): ss: County of ) I, (petitioner's name) ___________________________________, having been duly sworn, depose and state the following upon information and belief under the penalties of perjury: 1. a. I am a [check applicable box]: " peace or police officer " representative of the following duly authorized agency, association, society or institution [specify]: " person designated by the Court to file a family offense petition pursuant to FCA §822(d). b. I am submitting this affidavit in support of the issuance of a temporary order of protection to protect [specify names of protected persons]: 2. The Family Court, County, is not in session at the present time. 3. The following family offense(s) was/were committed on (specify date): ________ by the abovenamed Respondent [Check box or boxes]: " Disorderly conduct " Menacing in the 2nd or 3rd degree " Harassment in the 1st or 2nd degree " Reckless endangerment " Assault in the 2nd or 3rd degree " Aggravated harassment in the 2nd degree " Attempted assault in 2nd or 3rd degree " Stalking " Criminal mischief " Sexual misconduct " Forcible touching " Sexual abuse in the 2nd 1 or 3rd degree " Strangulation " Criminal obstruction of breathing or circulation " Identity theft in 1st, 2nd or 3rd degree " Grand larceny in 3rd or 4th degree " Coercion in 2nd degree [Penal Law §135.60 (1),(2),or (3) 1 Where victim is incapable of consent for reason other than being under age 17 [Penal Law §130.60(1)]. American LegalNet, Inc. www.FormsWorkFlow.com Family Court General Form 5c\Crim 4 Page 2 " " " " " " " 4. a. The above family offense(s) were committed against [specify]: b. The relationship of Respondent to the victim of the above family offense is [check box]: They are married They were married They have a child in common They are parent and child They are related by blood or marriage [specify how]: They have an intimate relationship (NOT casual social or business acquaintances) [describe]: They had an intimate relationship (NOT casual social or business acquaintances)[describe]: 5. [Check box]: " I filed a petition under Article 8 of the Family Court Act in Family Court,_____________County, on [specify date]:__________. " I intend to file a petition in Family Court, ____________County, on the next day the Court is in session. " The above-named victim filed a petition under Article 8 of the Family Court Act in Family Court,______________County, on [specify date]:__________. " The above-named victim informed me that (s)he intends to file a petition in Family Court, County, on the next day the Court is in session. 6. The following constitutes good cause for issuing a temporary order of protection:[Briefly describe family offense and any other facts and reasons supporting the need for protection of the abovenamed victim(s) and members of his/her/their households or families]: 7. a. The following criminal, matrimonial or Family Court cases have been filed involving the respondent and the proposed protected party or parties: [Specify type of case, who filed it, the court in which it was filed, the approximate date filed and the present status, if known]: b. The following orders of protection or temporary orders of protection have been issued against the respondent or against the proposed protected party or parties: [Specify type of case in which the order was issued, persons protected by the order, the court that. issued it, the approximate date issued and expiration date, if known]: 8. I understand and have informed the proposed protected party or parties that the Family Court order issued by this Court will expire on the date indicated on the order, which will be not more than four calendar days after its issuance, unless sooner vacated or modified by the Family Court. I understand and have informed the proposed protected party or parties that the matter will be transferred to the Family Court and that they must appear in Family Court on or before the date indicated and that, if I am or will be the Petitioner in Family Court, I must appear as well. I further understand and have informed the proposed protected party or parties that they and/or I have a right to seek a criminal prosecution of respondent in addition to, or instead of, proceeding in Family Court. WHEREFORE, for the reasons stated above, I am requesting that my application for a Family American LegalNet, Inc. www.FormsWorkFlow.com Family Court General Form 5c\Crim 4 Page 3 Court temporary order of protection be granted and that the matter be transferred to the Family Court, ________________ County. False statements in this affidavit are punishable as a class A misdemeanor, pursuant to Penal Law §210.45. Sworn to before me this day of ________________________ Petitioner __________________________ (JUDGE): (SUPERIOR OR DESK OFFICER, POLICE DEPARTMENT): (NOTARY PUBLIC): TO THE CLERK OF COURT: This affidavit, together with any temporary order of protection so issued, shall be transmitted forthwith to the Family Court; if the affidavit and order are transmitted by facsimile or other electronic means, the original shall be forwarded immediately thereafter. American LegalNet, Inc. www.FormsWorkFlow.com