Case No. Court County General Court of Justice District Court Division NORTH CAROLINA PETITIONER/PLAINTIFF First Middle Last EX PARTE DOMESTIC VIOLENCE ORDER OF PROTECTION PETITIONER/PLAINTIFF IDENTIFIERS Date Of Birth Of Petitioner G.S. 50B-2, -3, -3.1 And/or on behalf of minor family member(s): (List Name And DOB) Other Protected Persons/DOB: RESPONDENT/DEFENDANT First Middle Last VERSUS RESPONDENT/DEFENDANT IDENTIFIERS Sex Race DOB HT WT Eyes Hair Social Security Number State Expiration Date Relationship to Petitioner: spouse former spouse unmarried, of opposite sex, currently or formerly living together unmarried, have a child in common of opposite sex, currently or formerly in dating relationship current or former household member child parent grandchild grandparent Respondent's/Defendant's Address Drivers License No. Distinguishing Features CAUTION: Weapon Involved THE COURT HEREBY FINDS THAT: This matter was heard by the undersigned district court judge. magistrate. The court has jurisdiction over the subject matter. Additional findings of this order are set forth on Page 2. THE COURT HEREBY ORDERS THAT: The above named Respondent/Defendant shall not commit any further acts of domestic violence or make any threats of domestic violence (G.S. 50B-1). The above named Respondent/Defendant shall have no contact with the Petitioner/Plaintiff. No contact includes any defendant-initiated contact, except through an attorney, direct or indirect, by means such as telephone, personal contact, email, pager, gift-giving or telefacsimile machine. [05] Additional terms of this order are as set forth on Pages 3 and 4. The terms of this order shall be effective until , WARNINGS TO THE RESPONDENT/DEFENDANT: This order shall be enforced, even without registration, by the courts of any state, the District of Columbia, and any U.S. Territory, and may be enforced by Tribal Lands (18 U.S.C. Section 2265). Crossing state, territorial, or tribal boundaries to violate this order may result in federal imprisonment (18 U.S.C. Section 2262). This order will be enforced anywhere in North Carolina. Only the Court can change this order. The plaintiff cannot give you permission to violate this order. See additional warnings on Page 4. AOC-CV-304, Page 1 of 5, Rev. 12/15 � 2015 Administrative Office of the Courts (Over) American LegalNet, Inc. www.FormsWorkFlow.com ADDITIONAL FINDINGS 1. As indicated by the check block under Respondent/Defendant's name on Page 1, the parties are or have been in a personal relationship. , the defendant 2. That on (date of most recent conduct) a. the plaintiff the child(ren) living with attempted to cause intentionally caused bodily injury to or in the custody of the plaintiff the plaintiff a member of the plaintiff's family b. placed in fear of imminent serious bodily injury a member of the plaintiff's household c. placed in fear of continued harassment that rises to such a level as to inflict substantial emotional distress the plaintiff a member of plaintiff's household a member of plaintiff's family d. committed an act defined in G.S. 1427.27 (2nd deg. sexual off.) (describe defendant's conduct) 27.21 (1st deg. rape) 27.22 (2nd deg. rape) 27.26 (1st deg. sexual off.) 27.33 ( sexual battery) 27.31 (sexual activity by substitute parent) against the plaintiff a child(ren) living with or in the custody of the plaintiff by 3. The defendant is in possession of, owns or has access to firearms, ammunition, and gun permits described below. (Describe all firearms, ammunition, gun permits and give identifying number(s) if known, and indicate where defendant keeps firearms) 4. The defendant a. used threatened to use a deadly weapon against the plaintiff minor child(ren) residing with or in the custody of the plaintiff b. has a pattern of prior conduct involving the use threat ened use of violence with a firearm against persons c. made threats to seriously injure or kill the plaintiff minor child(ren) residing with or in the custody of the plaintiff d. made threats to commit suicide e. inflicted serious injuries upon the plaintiff minor child(ren) residing with or in the custody of the plaintiff in that (state facts): 5. The parties are the parents of the following child(ren) under the age of eighteen (18). The child(ren) are presently in the physical plaintiff. defendant. The plaintiff has submitted an "Affidavit As To Status Of Minor Child." custody of the NOTE TO JUDGE: A copy of AOC-CV-609 for each child must be attached to the order. Name Sex Date Of Birth Name Sex Date Of Birth 6. The minor child(ren) is exposed to a substantial risk of physical or emotional injury or sexual abuse in that: 7. It is in the best interest of and necessary for the safety of the minor child(ren) that defendant stay away from the minor child(ren) that the defendant return the minor child(ren) to plaintiff and that the defendant not remove the minor child(ren) from plaintiff in that: 8. (Check block only if plaintiff is entitled to physical care of child(ren).) It is in the best interest of the minor child(ren) that defendant have contact with the minor child(ren) in that: 9. The defendant plaintiff is presently in possession of the parties' residence at AOC-CV-304, Page 2 of 5, Rev. 12/15 � 2015 Administrative Office of the Courts (Over) American LegalNet, Inc. www.FormsWorkFlow.com Name Of Defendant File No. 10. The defendant plaintiff is presently in possession of the parties' vehicle. (describe vehicle) 11. Other: (specify) 12. (for magistrate only) This matter was heard at a time when the district court was not in session and a district court judge was not available and would not be available for a period of four or more hours. Based on these facts, the Court makes the following conclusions of law: 1. The defendant has committed acts of domestic violence against the plaintiff. 2. The defendant has committed acts of domestic violence against the minor child(ren) residing with or in the custody of the plaintiff. plaintiff. 3. It clearly appears that there is a danger of acts of domestic violence against the minor child(ren). [G.S. 50B-2(c)] physical injury. emotional injury. sexual abuse. 4. The minor child(ren) is exposed to a substantial risk of [G.S. 50B-2(c)] 5. The Court has jurisdiction under the Uniform Child Custody Jurisdiction And Enforcement Act. stay away from the minor 6. It is in the best interest of and necessary for the safety of the minor child(ren) that the defendant child(ren).