STATE OF NORTH CAROLINA County Name Of Petitioner/Employer Address Of Petitioner/Employer File No. In The General Court Of Justice District Court Division Name And Address Of Respondent VERSUS COMPLAINT FOR CIVIL NO-CONTACT ORDER PURSUANT TO THE WORKPLACE VIOLENCE PREVENTION ACT MOTION FOR TEMPORARY NO-CONTACT ORDER G.S. 95-262 NOTE TO PETITIONER: This Form is for use by employers only. If you are an individual that has been threatened, please refer to either the "Complaint and Motion for Domestic Violence Protective Order," AOC-CV-303, or the "Complaint for No-Contact Order for Stalking or Nonconsensual Sexual Conduct," AOC-CV-520. Check only the boxes below that apply and fill in blanks. Additional sheets may be attached. 1. The petitioner is an employer as defined by G.S. 95-260(2) in that: a. b. the petitioner is a person or entity that employs one or more employees. the petitioner is the State of North Carolina or one of its political subdivisions. 2. The unlawful conduct occurred in this county. 3. An employee of the petitioner has suffered unlawful conduct from the respondent and the unlawful conduct can be reasonably construed to be carried out, or to have been carried out, at the employee's workplace. The unlawful conduct consisted of: (Give specific dates and describe in detail what happened.) a. The respondent attempted to cause bodily injury or did intentionally cause bodily injury to the employee. b. The respondent willfully, and on more than one occasion, followed, was in the presence of, or otherwise harassed as defined in G.S. 14-277.3A, the employee without legal purpose and with the intent to place the employee in reasonable fear for the employee's safety. c. The respondent willfully threatened, orally, in writing or by any other means, to physically injure the employee in a manner and under circumstances that would cause a reasonable person to believe that the threat was likely to be carried out and that actually caused the employee to believe the threat would be carried out. 4. The employee that is the subject of the unlawful conduct was consulted prior to the filing of this Complaint and Motion in order to determine whether any safety concerns exist in relation to the employee's participation in the process. AOC-CV-530, New 7/11 © 2011 Administrative Office of the Courts (Over) American LegalNet, Inc. www.FormsWorkFlow.com Because Of These Acts Of Unlawful Conduct, The Petitioner Requests That The Court Grant The Following Relief: (Check only boxes that apply.) 1. A permanent no-contact order. (A permanent order cannot last longer than one year.) 2. A temporary no-contact order. (A temporary order cannot last longer than ten days.) 3. The temporary order to be issued ex parte (without notice to the defendant) because the plaintiff will suffer immediate injury, loss, or damage before the defendant can be heard in that: (explain) AND (If you checked Block 3 above check a. or b. below.) a. I certify that I have made the following efforts, if any, to give notice to the defendant and give the following reasons supporting why notice should not be required: (explain) b. I certify that there is good cause to grant the remedy because the harm that the remedy is intended to prevent would likely occur if the respondent was given any prior notice of the request for relief in that: (Give specific reasons why harm would occur if prior notice were given to defendant.) 4. An order directing the respondent: a. To not visit, assault, molest, or otherwise interfere with the employer or the employer's employee at the employer's workplace, or otherwise interfere with the employer's operations. b. To cease stalking the employer's employee at the employer's workplace. c. To cease harassment of the employer or the employer's employee at the employer's workplace. d. To not abuse or injure the employer, including the employer's property, or the employer's employee at the employer's workplace. e. To not contact by telephone, written communication, or electronic means the employer or the employer's employee at the employer's workplace. f. Other relief sought: 5. To treat this verified Complaint as an Affidavit for all purposes requiring an Affidavit. 6. Other: (specify) Date Signature Of Person Filing Complaint VERIFICATION I, the undersigned, being first duly sworn, say that I hold the position of (position with petitioner) in this action; that I have read the Complaint and Motion; that the matters and things alleged in the Complaint and Motion are true except as to those things alleged upon information and belief and as to those I believe them to be true and accurate. SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME Date Deputy CSC Assistant CSC Notary Signature Clerk Of Superior Court Designated Magistrate Date My Commission Expires County Where Notarized District Court Judge Date Signature Of Person Signing Complaint Name Of Person Filing Complaint (Type Or Print) SEAL AOC-CV-530, Side Two, New 7/11 © 2011 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com