FORM DC-383 (MASTER, PAGE ONE OF THREE) 07/19 RESPONDENT222S DESCRIPTION (IF KNOWN) RACE SEX BORN HT. WGT. EYES HAIR MO. DAY YR. FT. IN. SSN DRIVER222S LICENSE NO. STATE EXP. PETITION FOR PROTECTIVE ORDER Case No. ............................................................................................. Commonwealth of Virginia Va. Code 247247 19.2-152.9; 19.2-152.10 Hearing Date and Time ................................................................ [ ] General District Court [ ] Circuit Court ..................................................................................................................................................... [ ] Juvenile and Domestic Relations District Court ................................................................................................................................... PETITIONER v. ................................................................................................................................... RESPONDENT ................................................................................................................................... RESPONDENT222S ADDRESS/LOCATION ................................................................................................................................... Telephone no. (H) ....................................... (W) ......................................... The undersigned Petitioner respectfully represents to the court that: 1.A warrant or petition has been issued charging the Respondent with a criminal offense resulting from the commission of an act ofviolence, force, or threat; OR 2.The Respondent is committing or, within a reasonable time, has committed an act of violence, force, or threat,specifically: ...................................................................................................................................................................................................................................................... [ ] See accompanying affidavit. 3.[ ] Petitioner and Respondent cohabited, as intimate partners, more than 12 months ago but not within the previous 12 months. 4.[ ] A protective order of any type involving the parties is currently in effect. PETITIONER, THEREFORE, RESPECTFULLY REQUESTS that a protective order be issued, [ ] with [ ] without a preliminary protective order being issued prior to the full hearing, and that any order impose on the Respondent the following conditions and such conditions as the judge deems appropriate as allowed by law: [ ] Prohibiting acts of violence, force, or threat or criminal offenses that may result in injury to person or property. [ ] Prohibiting such other contact with the Petitioner as the judge deems necessary for the health and safety of the Petitioner. [ ] Prohibiting such other contact with the Petitioner222s family or household members named below, as the judge deems necessary for their health and safety. (Please provide on form DC-621, NON-DISCLOSURE ADDENDUM, the date of birth, gender, and race for each family or household member listed.) ............................................................................................................................................................................................................................................................................... NAMES OF FAMILY OR HOUSEHOLD MEMBERS SUMMONS FOR HEARING TO ANY AUTHORIZED OFFICER: Summon the Respondent as provided below: TO THE RESPONDENT: You are commanded to appear before this Court on ........................................................................................................ DATE AND TIME at ............................................................................................................................................................................................................ for a hearing on this Petition. NAME AND ADDRESS OF COURT ........................................................................... DATE ISSUED [ ] CLERK [ ] DEPUTY CLERK TO THE PETITIONER: Pleas e provide your information on form DC-621, NON-DISCLOSURE ADDENDUM. American LegalNet, Inc. www.FormsWorkFlow.com FORM DC-383 (MASTER, PAGE TWO OF THREE) 07/19 Case No. ................................................................................... [ ] Granting the Petitioner possession of the companion animal described as .............................................................................................................................. NAME/TYPE [ ] Such other conditions as the judge may deem necessary to prevent acts of violence, force or threat, criminal offenses resulting in injury to person or property, or communication or other contact of any kind by the Respondent, namely: ............................................................................................................................................................................................................................................................................... ............................................................................................. DATE PETITIONER ............................................................................................. by ATTORNEY222S ADDRESS AND TELEPHONE NUMBER PETITIONER222S ATTORNEY (When attested, this Petition shall also be an affidavit of the facts as stated in the Petition.) Sworn to and affirmed before me this .................. day of .................................................................... , 20 ................... [ ] INTAKE OFFICER (JUVENILE ONLY) [ ] CLERK[ ] NOTARY PUBLIC My commission expires: .................................................. Notary Registration No. ................................................... ................................................................................................................ DATE AND TIME FILED [ ] CLERK [ ] DEPUTY CLERK TO THE PETITIONER: You are summoned to appear in this court on ................................................................................................................ DATE [ ] CLERK [ ] DEPUTY CLERK American LegalNet, Inc. www.FormsWorkFlow.com FORM DC-383 (MASTER, PAGE THREE OF THREE) 07/19 RESPONDENT: Name: .................................................................................................. ............................................................................................................... Address ............................................................................................... ............................................................................................................... Tel. No. ............................................................................................... [ ] PERSONAL SERVICE Being unable to make personal service, a copy was delivered in the following manner: [ ] Delivered to family member (not temporary sojourner or guest) age 16 or older at usual place of abode of party named above after giving information of its purport. List name, age of recipient, and relation of recipient to party named above. ...................................................................................................... ...................................................................................................... [ ] Posted on front door or such other door as appears to be the main entrance of usual place of abode, address listed above. (Other authorized recipient not found.) [ ] Not Found SERVING OFFICE R ................................ for DATE ........................................... TIME PETITIONER: (See form DC-621, NON-DISCLOSURE ADDENDUM) Name: .................................................................................................. [ ] PERSONAL SERVICE Being unable to make personal service, a copy was delivered in the following manner: [ ] Delivered to family member (not temporary sojourner or guest) age 16 or older at usual place of abode of party named above after giving information of its purport. List name, age of recipient, and relation of recipient to party named above. ...................