COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : : : Defendant(s) : ...................................................... IN THE DISTRICT COURT OF THE STATE OF WASHINGTON IN AND FOR THE COUNTY OF KITSAP THE PEOPLE OF THE STATE OF NEW YORK TO NO. Petitioner GREETINGS: PETITION FOR ORDER vs. FOR PROTECTION (PTORPRT) (All Cases) WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , theRespondent Honorable at the Court located at County of 1. ¨ in room I am ¨ A member of my family or household is the20 , on the day of , victim , at 3. My age is: in the o'clock noon, and at any recessed ¨ Under the part or the of domestic violence committed by evidence as as or adjourned date, to testify and givethe respondent a witness in this action on 16 ¨ 16 of 17 ¨ 18 or over described in the statement below. Respondent's age is: ¨ I live in this county. ¨ Under 16 ¨ 16 or 17 ¨ 18 or over ¨ I left my residence because of abuse and this is the county Your failure to comply with of my new or former residence. this subpoena is punishable as a contempt of court and will make you liable to the4. My relationship with thethis subpoena was issued for a maximum penalty of $50 and all damages sustained as a party on whose behalf respondent is: ¨ Parent or child ¨ Have child in common ¨ Presently result ¨ Spouse of your failure to comply. ¨ In-law ¨ Presently reside together dating ¨ Former spouse ¨ Related by blood ¨ Resided together in past ¨ Dated in past Witness, of Minors (If applicable) ¨ No Minors involved. Honorable , one of the Justices of the 5. Identification Court in County, day of , 20 Name How Related to Resides 2. (First, Middle Initial, Last) Age Race Sex Petitioner Respondent with (Attorney must sign above and type name below) Attorney(s) for 6. Other court cases or other restraining, protection or no-contact orders involving me, the minors and the respondent: CASE NAME CASE NUMBER Office and P.O. Address COURT/COUNTY PETITION FOR ORDER FOR PROTECTION - Page 1 of 4 WPF DV-1.015 (9/2001) - RCW 26.50.030 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : JUDICIAL SUBPOENA Plaintiff(s) REQUEST FOR TEMPORARY ORDER: AN EMERGENCY EXISTS as described in the -against: statement below: I need a temporary restraining order issued immediately without notice to the respondent until a hearing to avoid irreparable injury. I request: a Temporary Order for Protection that will: : I REQUEST AN ORDER FOR PROTECTION following a hearing THAT WILL: 1. RESTRAIN respondent Defendant(s) any physical harm, bodily injury, assault, from causing : ...................................................... including sexual assault, and from molesting, harassing, threatening, or stalking ¨ me ¨ the minors named in paragraph 5 above ¨ these minors only: 2. RESTRAIN respondent from coming near and from having any contact whatsoever, THE PEOPLE OF THE STATE OF NEW YORK 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, TO subject to any court-ordered visitation ¨ these minors only, subject to any courtordered visitation: ¨ Except to coordinate visitation 3. EXCLUDE respondent from ¨ our shared residence ¨ my residence ¨ my workplace ¨ my school ¨ the daycare or school of minors named in paragraph 5 WE COMMAND YOU, minors only: above ¨ these that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court ¨ other: located at County of the of in room , on You have day right to keep your address confidential in the the , 20 , at o'clock noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 4. DIRECT respondent to vacate our shared residence and restore it to me. GREETINGS: 5. RESTRAIN respondent from entering, knowingly coming within, or knowingly ¨ remaining within 500 feet of my ¨ residence ¨ my workplace ¨ my school Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to day care or school of ¨ the minors named in paragraph 5 above. the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a ¨ these minors only: result of your failure to comply. ¨ other: Witness,6. GRANT me possession of essential personal belongings, includingJustices of the Honorable , one of the the following: Court in County, day of , 20 7. Grant me use of the following vehicle: Year, Make & Model License No. (Attorney must sign above and type name below) 8. OTHER: Attorney(s) for 9. DIRECT the respondent to participate in appropriate treatment or counseling services. 10. REMAIN EFFECTIVE longer than one year because respondent is likely to Office and expires in a year. resume acts of domestic violence against me if the order P.O. Address PETITION FOR ORDER FOR PROTECTION - Page 2 of 4 WPF DV-1.015 (6/2002) - RCW 26.50.030 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. Check the following only if you are requesting protection involving a minor: : JUDICIAL Plaintiff(s) SUBPOENA 11. Subject to any court-ordered visitation, GRANT me the care, custody and control -against: of ¨ the minors named in paragraph 5 above ¨ these minors only: : 12. RESTRAIN respondent from interfering with my physical or legal custody of ¨ the minors named in paragraph 5 above ¨ these: minors only: 13. RESTRAIN the respondent from removing from the state: ¨ the minors named in Defendant(s) : . . . . . . . . . . . . . . . paragraph .5. above. ¨ .these. minors. only:. . . . . . . ........ .... .. ... ..... .... REQUEST FOR SPECIAL ASSISTANCE FROM LAW ENFORCEMENT AGENCIES: I request the Court order the appropriate law enforcement agency to assist me in obtaining: THE PEOPLE OF THEmy residenceNEW YORK ¨ Possession of STATE OF ¨ Use of designated vehicle. ¨ Possession of my essential personal belongings at ¨ the shared residence ¨ respondents TO residence ¨ other: ¨ Custody of ¨ the minors named in paragraph 5 above ¨ these minors only (If applicable): . . GREETINGS: ¨ OTHER: . WE COMMAND YOU, that all harm, bodily injury, assault, stalking, you and each of of Domestic violence includes physical business and excuses being laid aside,OR inflicting fearyou attend before , the Honorable physical harm, bodily injury or assault the at between family or household members. Court imminent located at County of inSTATEMENT: ,Thethe room on respondent has committed acts of domestic violence asin the day of , 20 , at o'clock follows. (Describe specificrecessed noon, and at any oracts of domestic violence and their approximatea witness in this actionthe most recentthe You may adjourned date, to testify and give evidence as dates, beginning with on the part of act. want to include police responses.) Describe the most recent incident or threat of violence and date: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Attorney(s) for ____________________________________________________________________________________________ ___________Describe the past incidents where you were experienced violence, where you were afraid of injury or where the respondent threatened to harm or kill you: Office and P.O. Address PETITION FOR ORDER FOR PROTECTION Page 3 of 4 WPF DV-1.015 (9/2001) - RCW 26.50.030 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) Calendar No. : JUDICIAL SUBPOENA ____________________________________________________________________________________________ -against: ____________________________________________________________________________________________ ____________________________________________________________________________________________ : ____________________________________________________________________________________________ ___________Describe any violence or threats towards children: : Defendant(s) : ...................................................... Describe medical treatment you received and for what: THE PEOPLE OF THE STATE OF NEW YORK TO Describe any threats of suicide or suicidal behavior by the respondent:____________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ GREETINGS: ____________________________________________________________________________________________ _________ COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before WE Does the respondent own or possess firearms? ¨ Yes at the ¨ No , the Honorable Court located at Does of Countythe respondent use firearms, weapons or objects to threaten or harm you? Please describe: in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the If you are requesting that the protection ordersubpoena isthan one year, describe the reasons why: will make you liable to Your failure to comply with this lasts longer punishable as a contempt of court and the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the Other: day of , 20 (Continue on separate page if necessary) Check box if substance abuse is involved: ¨ alcohol ¨ controlled drugs ¨ other sign above and type name below) (Attorney must I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Attorney(s) for DATED at Poulsbo, Washington. Signature of Petitioner Office and P.O. Address You have the 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: Telephone No.: Facsimile No.: E-Mail Address: PETITION FOR ORDER FOR PROTECTION Page 4 of 4 WPF DV-1.015 (9/2001) - RCW 26.50.030 Mobile Tel. No.: Revised 06/07/04 American LegalNet, Inc. www.USCourtForms.com