State of Washington King County District Court East Division, Bellevue Courthouse No. Petitioner Petition for Order for Protection vs. (PTORPRT) Respondent 1. I am a victim of domestic violence committed by the respondent. A member of my family or household is a victim of domestic violence committed by the respondent. I am a guardian guardian ad litem next friend of a minor who is 13 to 15 years of age and is a victim of domestic violence in a dating relationship with a person age 16 or older. The name of the minor victim is _________________________________________. This person’s identifying information is provided in paragraph 5 below. 2. The victim lives in this county. The victim left their residence because of abuse and this is the county of their new or former residence. 3. The victim’s age is: Respondent's age is: Under 16 16 or 17 18 or over Under 16 16 or 17 18 or over 4. The victim’s relationship with the respondent is: spouse or former spouse parent of a common child current or former cohabitant as intimate partner, including current or former registered domestic partner current or former dating relationship stepparent or stepchild current or former cohabitant as roommate in-law parent or child blood relation other than parent or child Petition for Order for Protection (PTORPRT) - Page 1 of 6 WPF DV-1.015 Mandatory (6/2010) - RCW 26.50.030 American LegalNet, Inc. www.FormsWorkFlow.com 5. Identification of Minors (if applicable) Name (First, Middle Initial, Last) Age No Minors involved. Race Sex How Related to Petitioner Respondent Resides with 6. Other court cases or other restraining, protection or no-contact orders involving me, the minors and the respondent: Case Name Case Number Court/County Check the box for each type of relief you are requesting, for each type of order you need. Temp: I Request a Temporary Order for Protection, effective until the hearing, because an Emergency Exists as described in the statement below. A temporary protection order should be issued immediately without notice to the respondent, to avoid irreparable injury. Full: I Request a “full” Order for Protection, following a hearing. Temp Full ↓ ↓ 1 Restrain respondent from causing any physical harm, bodily injury, assault, including sexual assault, and from molesting, harassing, threatening, or stalking me the minors named in paragraph 5 above these minors only: (If the court orders this relief, and the respondent is your spouse or former spouse, the parent of a common child, or a current or former cohabitant as intimate partner, including a current or former registered domestic partner, the respondent will be prohibited from possessing a firearm or ammunition under federal law for the duration of this order. An exception exists for law enforcement officers and military personnel when carrying department/government-issued firearms. 18 U.S.C. § 925(a)(1).) 2 Restrain respondent from harassing, following, keeping under physical or electronic surveillance, cyberstalking as defined in RCW 9.61.260, and using telephonic, audiovisual, or other electronic means to monitor the actions, locations, or wire or electronic communication of me the minors named in paragraph 5 above only the minors listed below; members of the victim’s household listed below the victim’s adult children listed below: Petition for Order for Protection (PTORPRT) - Page 2 of 6 WPF DV-1.015 Mandatory (6/2010) - RCW 26.50.030 American LegalNet, Inc. www.FormsWorkFlow.com Temp ↓ Full Temporary Order, effective until a hearing. Full Order, effective following a hearing. ↓ 3 Restrain respondent from coming near and from having any contact whatsoever, in person or through others, by phone, mail, or any means, directly or indirectly, except for mailing of court documents, with me the minors named in paragraph 5 above, subject to any court-ordered visitation these minors only, subject to any court-ordered visitation: 4 Exclude respondent from our shared residence my residence my workplace my school the residence, day care, or school of named in paragraph 5 above these minors only: the minors other: You have a right to keep your residential address confidential. 5 Direct respondent to vacate our shared residence and restore it to me. 6 Prohibit respondent from knowingly coming within, or knowingly remaining within __________________ (distance) of our shared residence my residence my workplace my school the day care or school of the minors named in paragraph 5 above. these minors only: other: 7 Grant me possession of essential personal belongings, including the following: 8 Grant me use of the following vehicle: Year, Make & Model _____________________________ License No. 9 N/A N/A N/A Other: 10 Direct the respondent to participate in appropriate treatment or counseling services. 11 Require the respondent to pay the fees and costs of this action. 12 Remain Effective longer than one year because respondent is likely to resume acts of domestic violence against me if the order expires in a year. Check the following only if you are requesting protection involving pets. N/A 13 Grant me exclusive custody and control of the following pet(s) owned, possessed, leased, kept, or held by me, respondent, or a minor child residing with either me or the respondent. (Specify name of pet and type of animal.): ___________________________________________________________________. Petition for Order for Protection (PTORPRT) - Page 3 of 6 WPF DV-1.015 Mandatory (6/2010) - RCW 26.50.030 American LegalNet, Inc. www.FormsWorkFlow.com N/A N/A 14 Prohibit respondent from interfering with my efforts to remove the pet(s) named above. 15 Prohibit respondent from knowingly coming within, or knowingly remaining within _______________ (distance) of the following locations where the pet(s) are regularly found: petitioner's residence (You have a right to keep your residential address confidential.) _____________________________________________ Park other:___________________________________________________________ Check the following only if you are requesting protection involving a minor: 16 Subject to any court-ordered visitation, Grant me the care, custody and control of the minors named in paragraph 5 above these minors only: 17 Restrain respondent from interfering with my physical or legal custody of the minors named in paragraph 5 above these minors only: 18 Restrain the respondent from removing from the state: paragraph 5 above these minors only: the minors named in Request for Special Assistance From Law Enforcement Agencies: I request the court order the appropriate law enforcement agency to assist me in obtaining: Possession of my residence. Possession of the vehicle designated above. Possession of my essential personal belongings at the shared residence respondent’s residence other location _______________________________________________________. Custody of the minors named in paragraph 5 above these minors only (if applicable): . Other: . “Domestic violence” means physical harm, bodily injury, assault, including sexual assault, stalking, Or inflicting fear of imminent physical harm, bodily injury or assault between family or household members. Statement: The respondent has committed acts of domestic violence as follows. (Describe specific acts of domestic violence and their approximate dates, beginning with the most recent act. You may want to include police responses.) Describe the most recent incident or threat of violence and date: Petition for Order for Protection (PTORPRT) - Page 4 of 6 WPF DV-1.015 Mandatory (6/2010) - RCW 26.50.030 American LegalNet, Inc. www.FormsWorkFlow.com Describe the past incidents where you experienced violence, where you were afraid of injury or where the respondent threatened to harm or kill you: . Describe any violence or threats towards children: . Describe any stalking behavior by respondent, including use of telephonic, audiovisual or electronic means to harass or monitor: Describe medical treatment you received and for what: . Describe any threats of suicide or suicidal behavior by the respondent: Petition for Order for Protection (PTORPRT) - Page 5 of 6 WPF DV-1.015 Mandatory (6/2010) - RCW 26.50.030 American LegalNet, Inc. www.FormsWorkFlow.com Does the respondent own or possess firearms? Yes No Does the respondent use firearms, weapons or objects to threaten or harm you? Please describe: If you are requesting that the protection order lasts longer than one year, describe the reasons why: Other: (Continue on separate page if necessary.) Check box if substance abuse is involved: alcohol drugs other Personal service cannot be made upon respondent within the state of Washington. I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Dated: at , Washington. Signature of Petitioner You have a right to keep your residential address confidential. If you have one, please provide an address, other than your residence, where you may receive legal documents: . Petition for Order for Protection (PTORPRT) - Page 6 of 6 WPF DV-1.015 Mandatory (6/2010) - RCW 26.50.030 American LegalNet, Inc. www.FormsWorkFlow.com