FORM 10.01-J: CONSENT AGREEMENT AND DOMESTIC VIOLENCE CIVIL PROTECTION ORDER IN THE COURT OF COMMON PLEAS COUNTY, OHIO Case No. Order of Protection Per R.C. 3113.31(F)(3), this Order is indexed at Judge County OHIO State LAW ENFORCEMENT AGENCY WHERE INDEXED ( ) CONSENT AGREEMENT AND DOMESTIC VIOLENCE CIVIL PROTECTION ORDER (R.C. 3113.31) WITH SUPPORT ORDER PHONE NUMBER PETITIONER: First Middle PERSON(S) PROTECTED BY THIS ORDER: DOB Petitioner: Petitioner’s Family or Household Member(s)(May attach additional forms): DOB DOB DOB DOB Last v. RESPONDENT: SEX RESPONDENT IDENTIFIERS RACE HT EYES First Middle HAIR WT DATE OF BIRTH Last DRIVER’S LIC. NO. EXP. DATE STATE Relationship to Petitioner: Address where Respondent can be found: Distinguishing Features: WARNING TO LAW ENFORCEMENT: RESPONDENT HAS FIREARMS ACCESS – PROCEED WITH CAUTION (Violence Against Women Act, 18 U.S.C. 2265, Federal Full Faith & Credit Declaration: Registration of this Order is not required for enforcement.) THE COURT HEREBY FINDS: That it has jurisdiction over the parties and subject matter, and the Respondent was provided with reasonable notice and opportunity to be heard within the time required by Ohio law. Additional findings of this Order are set forth below. THE COURT HEREBY ORDERS: That the above named Respondent be restrained from committing acts of abuse or threats of abuse against the Petitioner and other protected persons named in this Order, as set forth below. Additional terms of this Order are set forth below. The terms of this Order shall be effective until / / (DATE CERTAIN – FIVE YEARS MAXIMUM) WARNING TO RESPONDENT: See the warning page attached to the front of this Order. FORM 10.01-J: CONSENT AGREEMENT AND DOMESTIC VIOLENCE CIVIL PROTECTION ORDER Amended: July 1, 2010 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Page 2 of Form 10.01-J] Case No.__________________________ This proceeding came on for a hearing on . The following individuals were present: before the Court and the Ex Parte Order filed on The parties agree to waive their notice and hearing rights and their rights under Civ. R. 53, including the right to request findings of fact and conclusions of law and to file objections to the Magistrate’s Decision in this matter. ALL OF THE PROVISIONS CHECKED BELOW APPLY TO THE RESPONDENT. 1. RESPONDENT SHALL NOT ABUSE the protected persons named in this Order by harming, attempting to harm, threatening, following, stalking, harassing, forcing sexual relations upon them, or by committing sexually oriented offenses against them. [NCIC 01 and 02] 2. RESPONDENT SHALL IMMEDIATELY VACATE the following residence: 3. EXCLUSIVE POSSESSION OF THE RESIDENCE located at: is granted to: . Respondent shall not interfere with this individual’s right to occupy the residence including, but not limited to canceling utilities or insurance, interrupting telephone service, mail delivery, or the delivery of any other documents or items. [NCIC 03] 4. RESPONDENT SHALL SURRENDER all keys and garage door openers to the above residence at the earliest possible opportunity after service of this Order to the law enforcement agency that serves Respondent with this Order or as follows: 5. RESPONDENT SHALL NOT ENTER or interfere with the residence, school, business, place of employment, day care center, or child care providers of the protected persons named in this Order, including the buildings, grounds, and parking lots at those locations. Respondent may not violate this Order even with the permission of a protected person. [NCIC 04] 6. RESPONDENT SHALL STAY AWAY FROM PETITIONER and all other protected persons named in this Order and not be present within 500 feet or (distance) of any protected persons, wherever those protected persons may be found, or any place the Respondent knows or should know the protected persons are likely to be, even with Petitioner’s permission. If Respondent accidentally comes in contact with protected persons in any public or private place, Respondent must depart immediately. This Order includes encounters on public and private roads, highways, and thoroughfares. [NCIC 04] 7. RESPONDENT SHALL NOT INITIATE OR HAVE ANY CONTACT with the protected persons named in this Order or their residences, businesses, places of employment, schools, day care centers, or child care providers. Contact includes, but is not limited to, telephone, fax, e-mail, voice mail, delivery service, writings, or communications by any other means in person or through another person. Respondent may not violate this Order even with the permission of a protected person. [NCIC 05] 8. RESPONDENT SHALL IMMEDIATELY SURRENDER POSSESSION OF ALL KEYS TO THE FOLLOWING , to the law enforcement agency that served Respondent with the MOTOR VEHICLE, Order or as follows and Petitioner is granted exclusive use of this motor vehicle. 9. RESPONDENT SHALL NOT REMOVE, DAMAGE, HIDE, OR DISPOSE OF ANY PROPERTY OR PETS owned or possessed by the protected persons named in this Order. Personal property shall be apportioned as follows: 10. RESPONDENT SHALL NOT CAUSE OR ENCOURAGE ANY PERSON to do any act prohibited by this Order. FORM 10.01-J: CONSENT AGREEMENT AND DOMESTIC VIOLENCE CIVIL PROTECTION ORDER Amended: July 1, 2010 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Page 3 of Form 10.01-J] Case No.___________________________ 11. RESPONDENT SHALL NOT POSSESS, USE, CARRY, OR OBTAIN ANY DEADLY WEAPON. Respondent shall turn over all deadly weapons in Respondent’s possession to the law enforcement agency that serves Respondent with this Order or as follows: Any law enforcement agency is authorized to take possession of deadly weapons pursuant to this paragraph and hold them in protective custody until further Court order. [NCIC 07] 12. PARENTAL RIGHTS AND RESPONSIBILITIES ARE TEMPORARILY ALLOCATED AS FOLLOWS: [NCIC 09] This Order applies to the following child(ren): 13. VISITATION ORDERS DO NOT PERMIT RESPONDENT TO VIOLATE THE TERMS OF THIS ORDER. (A) Respondent's visitation rights are suspended; or (B) As a limited exception to paragraphs 6 and 7, temporary visitation rights are established as follows: [NCIC 06] This Order applies to the following child(ren): 14. LAW ENFORCEMENT AGENCIES, including, but not limited to, are ordered to assist Petitioner in gaining physical custody of the child(ren) if necessary. 15. RESPONDENT SHALL SUPPORT the protected persons named in this Order as follows: 16. RESPONDENT MAY PICK UP CLOTHING and personal items from the above residence only in the company of a uniformed law enforcement officer within seven days of the filing of this Order. Arrangements may be made by contacting: 17. RESPONDENT SHALL NOT USE OR POSSESS alcohol or illegal drugs. 18. IT IS FURTHER ORDERED: [NCIC 08] 19. RESPONDENT SHALL COMPLETE THE FOLLOWING COUNSELING PROGRAM: Respondent shall contact this program within days after receiving this Order and immediately arrange for an initial appointment. The counseling program is requested to provide the Court a written notice when Respondent attends the initial appointment, if the Respondent fails to attend or is discharged, and when Respondent completes the program. Respondent is required to sign all necessary waivers to allow the Court to receive information from the counseling program. Respondent is ordered to appear before Judge or Magistrate on at a.m. / p.m, to review Respondent’s compliance with the counseling order. Respondent is warned: If you fail to attend the counseling program you may be held in contempt of court. If you fail to appear at this hearing, the Court may issue a warrant for your arrest. FORM 10.01-J: CONSENT AGREEMENT AND DOMESTIC VIOLENCE CIVIL PROTECTION ORDER Amended: July 1, 2010 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Page 4 of Form 10.01-J] Case No.___________________________ 20. IT IS FURTHER ORDERED that the Clerk of Court shall cause a copy of the Petition and this Order to be delivered to the Respondent as required by law. The Clerk of Court shall also provide certified copies of the Petition and this Order to Petitioner upon request. This Order is granted without bond. Under federal and state law the Clerk shall not charge any fees for filing, issuing, registering, or serving this Protection Order. 21. ALL OF THE TERMS OF THIS ORDER REMAIN IN FULL FORCE AND EFFECT FOR A PERIOD OF FIVE unless earlier modified or terminated by order of this YEARS FROM ISSUANCE, OR UNTIL Court. Except for paragraphs 12, 13, 14, and 15 above, this Order survives a divorce, dissolution of marriage, or legal separation. Until this Order is delivered to Respondent, the terms of the Ex Parte CPO remain in effect. IT IS SO ORDERED. APPROVED and ADOPTED by: MAGISTRATE JUDGE NOTICE TO RESPONDENT: THE PERSONS PROTECTED BY THIS ORDER CANNOT GIVE YOU LEGAL PERMISSION TO CHANGE OR VIOLATE THIS ORDER. IF YOU VIOLATE ANY TERMS OF THIS ORDER, EVEN WITH THE PROTECTED PERSON’S PERMISSION, YOU MAY BE ARRESTED. ONLY THE COURT CAN CHANGE THIS ORDER. IF THERE IS ANY REASON WHY THIS ORDER SHOULD BE CHANGED, YOU MUST ASK THE COURT TO CHANGE IT. YOU ACT AT YOUR OWN RISK IF YOU DISREGARD THIS WARNING. I have read this Consent Agreement and Civil Protection Order and agree to its terms. I have read this Consent Agreement and Civil Protection Order and agree to its terms. SIGNATURE OF PETITIONER SIGNATURE OF RESPONDENT Address of Petitioner Address of Respondent Signature of Attorney for Petitioner Signature of Attorney for Respondent Address of Attorney for Petitioner Address of Attorney for Respondent TO THE CLERK COPIES OF THIS ORDER SHALL BE DELIVERED TO: NOTICE OF FINAL APPEALABLE ORDER Copies of the foregoing Order, which is a final Petitioner Attorney for Petitioner Respondent Attorney for Respondent Counseling Program: The County Sheriff’s Office Police Department Where Petitioner Resides: appealable order, were mailed by ordinary U.S. mail or hand-delivered to the parties indicated on the day of By: CLERK OF COURT , 20 . Police Department Where Petitioner Works: CSEA Other: FORM 10.01-J: CONSENT AGREEMENT AND DOMESTIC VIOLENCE CIVIL PROTECTION ORDER Amended: July 1, 2010 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com