IN THE KITSAP COUNTY SUPERIOR COURT I N THE KITSAP COUNTY DISTRICT COURT I N THE BAINBRIDGE ISL AND MUNICIPAL COURT I N THE BREMERTON MUNICIPAL COURT I N THE PORT ORC HAR D MUNICIPAL COURT I N THE POULS BO MUNICIPAL COURT STATE OF WASHINGTON, LAW ENFORCEMENT NO. __________________ CITY OF BAINBRIDGE ISLAND, CITY OF BREMERTON, PRE-ARRAIGNMENT DOMESTIC CITY OF PORT OR CHAR D, VIOLENCE NO CONTACT ORDER CITY OF POULSBO, ( ) Plaintiff, Date of Arrest: ____________________________ Time of Arrest: ____________________________ vs. Arresting Officer/No.:________________________ Bainbridge Island Police Department ________________________________________, Bremerton Police Department Kitsap County Sheriffs Office DOB: _________________________ Port Orchard Police Department Poulsbo Police Department Defendant. Washington State Patrol THE COURT FINDS THAT the Defendant has been arrested for a domestic violence offense, and further finds that to prevent possible recurrence of violence, this Pre-Arraignment Domestic Violence No Contact Order shall be entered pursuant to chapter 10.99 RCW. The person(s) protected by this order are __________________________________________________________________________________ (Protected person(s) name, or initials if a minor, and DOB) IT IS ORDERED THAT Defendant is PROHIBITED from causing or attempting to cause physical harm, bodily injury, assault, including sexual assault, and from molesting, harassing, threatening, or stalking the protected person(s), and IT IS ORDERED THAT Defendant is PROHIBITED 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 or service of process of court documents by a third party or contact by the Defendants lawyer(s) with the protected person(s), and IT IS ORDERED THAT Defendant is PROHIBITED from entering or knowingly coming within or knowingly remaining within 500 feet of the protected persons residence, school, or place of work, and IT IS ORDERED THAT this Pre-Arraignment Domestic Violence No Contact Order expires seven (7) days from the date below. PRE- AR R AIGNMENT DOMESTIC VIOLENCE NO CONTACT ORDER (6/03) - 1 - G:\SCRT\DATAF ORMS\Pre-Arraignment DV No Contact Order.doc >>>> 2 WARNINGS TO THE DEFENDANT : Violation of the provisions of this order with actual notice of its terms is a criminal offense under chapter 26.50 RCW, and will subject a violator to arrest. If the violation of this order involves travel across a state line or the boundary of a tribal jurisdiction, or involves conduct within the special maritime and territorial jurisdiction of the United States, which includes tribal lands, the you may be subject to criminal prosecution in federal court under 18 U.S.C. sections 2261, 2261A, or 2262. Any assault, drive-by shooting, or reckless endangerment that is a violation of this order is a felony. Any conduct in violation of this order that is reckless and creates a substantial risk of death or serious physical injury to another person is a class C felony. Effective immediately, and continuing as long as this order is in effect, you may not possess a firearm or ammunition. 18 U.S.C. section 922(g)(8). A violation of this federal firearms law carries a maximum possible penalty of 10 years in prison and a $250, 000 fine. An exception exists for law enforcement officers and military personnel when carrying department/government-issued firear ms. 18 U.S.C. section 925(a)(1). If you are convicted of an offense of domestic violence, you will be forbidden for life from possessing a firearm or ammunition. 18 U.S.C. section 922(g) (9); RCW 9.41.040. YOU CAN BE ARRESTED EVEN IF ANY PERSON OR PERSONS PROTECTED BY THIS ORDER INVITES OR ALLOWS YOU TO VIOLATE THIS ORDER S PROHIBITIONS . You have the sole responsibility to avoid or refrain from violating the ordersovisions. Only the court prcan change the order. Pursuant to 18 U.S.C. section 2265, a court in any of the 50 states, the District of Columbia, Puerto Rico, any United States territory, and any tribal land within the United States shall accord full faith and credit to the order. Dated: ____________________ I agree to abide by the terms of this Pre-Arraignment Domestic Violence No Contact Order. I understand that the AM PM] terms of any other court orders remain in effect notwithstanding the expiration of this order. ___________________________________________ DEFENDANT SO ORDERED . _______________________________________________ JUDGE __________________________________________ Presiding Judge of the ________________________ Court Original (Prosecutors Office) Copy (Defendant) Copy (Law Enforcement Agency) PRE-ARRAIGNMENT DOMESTIC VIOLENCE NO CONTACT ORDER (6/03) - 2 - G:\SCRT\DATA\)-16(FORMS\Pre-Arraignment DV No Contact Order.doc