F.C.A. 446, 551, 656, 842 & 1056 ORI No: Order No: NYSID No:- General Form 5a 12/2013 At a Term of the County of (address) Court ,State of New York PRESENT: Hon. In the Matter of a Proceeding under Of the Family Court Act Article Petitioner Date of Birth: v. Respondent Date of Birth: ORDER OF PROTECTION [Articles 4, 5, 6, 8 and 10] Docket No. Family Unit No. (check one) " Upon Default " Both Parties Present In Court NOTICE: YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY SUBJECT YOU TO MANDATORY ARREST AND CRIMINAL PROSECUTION, WHICH MAY RESULT IN YOUR INCARCERATION FOR UP TO SEVEN YEARS FOR CRIMINAL CONTEMPT, AND/OR MAY SUBJECT YOU TO FAMILY COURT PROSECUTION AND INCARCERATION FOR UP TO SIX MONTHS FOR CONTEMPT OF COURT. THIS ORDER OF PROTECTION WILL REMAIN IN EFFECT EVEN IF THE PROTECTED PARTY HAS, OR CONSENTS TO HAVE, CONTACT OR COMMUNICATION WITH THE PARTY AGAINST WHOM THE ORDER IS ISSUED. THIS ORDER OF PROTECTION CAN ONLY BE MODIFIED OR TERMINATED BY THE COURT. THE PROTECTED PARTY CANNOT BE HELD TO VIOLATE THIS ORDER NOR BE ARRESTED FOR VIOLATING THIS ORDER. , having been filed in this A petition under Article of the Family Court Act, sworn to on Court in the above-entitled proceeding,, 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 this Court [check applicable box]: " after hearing " on consent , having determined that good cause has been shown for the issuance of this Order, NOW, THEREFORE, IT IS HEREBY ORDERED that [specify first name, middle initial and last name]: must 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 or 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, identity theft, grand larceny, coercion 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)]: American LegalNet, Inc. www.FormsWorkFlow.com GF-5-a Page 2 [11] " Permit [specify individual]: [specify law enforcement agency, if any]: litigation [specify items]: to enter the residence at [specify]: with during [specify date/time]: to remove personal belongings not in issue in ; [04] " Refrain from [indicate acts]: that create an unreasonable risk to the health, safety or welfare of [specify child(ren), family or household member(s) ]: ; [05] " Permit [specify individual]: other written agreement to visit with [specify child(ren)]: during the following periods of time [specify]: and conditions [specify]: , entitled by a court order or separation or under the following terms ; shall be [07] " Custody of [specify child(ren)]: under the following terms and conditions [specify]: awarded to [specify individual]: _____________________________________________________________________________ ; _____________ [12] " Surrender any and all handguns, pistols, revolvers, rifles, shotguns and other firearms owned or possessed, and do not obtain any further guns including, but not limited to, the following: or other firearms. Such surrender shall take place immediately, but in no event later than [specify date/time]: ; at [specify location]: [ ] ` Promptly return or transfer the following identification documents specify]: ____________________________________________________________________________________to the party in the following protected by this Order NOT LATER THAN [specify date]: manner [specify manner or mode of return or transfer]: ____________________________________________ [Check box(es) if applicable]: ` Such documents shall be made available for use as evidence in this judicial proceeding. ` [Jointly owned documents or documents in both parties' names only]: The following document(s) may be used as necessary for legitimate use by the . Respondent [specify]: " 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] ; Arts. 5,6&8 only " Pay counsel fees (and/or) any costs associated with the order to [specify person and terms] ; Arts. 4,5&6 only " Participate in an educational program, (and pay the costs thereof)[(specify program] ; Art. 8 only " Participate in a batterer's education program designed to help end violent behavior (and pay the ; costs thereof)[specify program] Art. 8 only " Pay to the petitioner/victim(s) restitution, as follows [specify terms and amount up to $1 0,000]: ; and [99] " Observe such other condition(s) as are necessary to further the purposes of protection [specify conditions]: ; Art. 8 only [check if applicable]: " Respondent is on probation [FCA§842 requires order to state if Respondent is on probation]. American LegalNet, Inc. www.FormsWorkFlow.com GF-5-a Page 3 AGGRAVATING CIRCUMSTANCES FINDING [check box and fill in if applicable]: " The court has made a finding on the record of the existence of the following AGGRAVATING CIRCUMSTANCES: It is further ordered that the above-named Respondent's license to carry, possess, repair, sell or otherwise dispose of a firearm or firearms, if any, pursuant to Penal Law '400.00, is [check applicable box(es)]: [13A] " suspended, or [13B] "revoked, (note: final order only) and/or [13C] " the Respondent shall remain ineligible to receive a firearm license while this Order is in effect. It is further ordered that this order of protection shall remain in force until and including [specify date]: The Family Court Act provides that presentation of a copy of this order of protection to any police officer or peace officer acting pursuant to his or her special duties authorizes, and