Superior Court of Washington County of In re the Custody of: Child(ren), Petitioner(s), and Respondent(s). No. Motion/Declaration for Ex Parte Restraining Order and for Order to Show Cause (Nonparental Custody) (MTSC) I. Motion Based upon the reasons set forth in the declaration below, (name of requesting party) _______________________________________ moves the court for a temporary order and order to show cause. 1.1 Ex Parte Restraining Order A temporary restraining order should be granted without written or oral notice to (name of other party) ___________________________________________or the other party's lawyer because immediate and irreparable injury, loss, or damage will result before the other party or the other party's lawyer can be heard in opposition. This order should restrain or enjoin: [] [] [] [] (Name) ______________________________ from disturbing the peace of (name(s)) __________________________________________________________. (Name) ______________________________ from going onto the grounds of or entering the home, work place or school of the requesting party, or the day care or school of the following named children: _________________________________________________. (Name) ____________________________________________ from knowingly coming within or knowingly remaining within (distance)__________________ of the home, work place or school of the requesting party or the day care or school of the following children: _______________________________________________________________________. (Name) ________________________________ from molesting, assaulting, harassing, or stalking (name(s))____________________________________________. Mtn/Decl for Ex Parte Restraining Ord (MTSC) - Page 1 of 6 WPF CU 03.0150 Mandatory (6/2008) - CR 65 (b); RCW 26.10.115 American LegalNet, Inc. www.FormsWorkflow.com [] [] (Name) ______________________________ from removing any of the children from the state of Washington. Other: (Name) ______________________________ should be required to appear and show cause why these restraints should not be continued in full force and effect pending final determination of this action. 1.2 Other Ex Parte Relief [] [] 1.3 Order that (name) ______________________________ shall be the person with whom the children reside until the hearing. Other: Surrender of Deadly Weapons [] [] Does not apply. (If this box is checked, clear and convincing reasons for this request must be presented in paragraph 2.4 below.) The court should require (name) ______________________________ to surrender any deadly weapon in his or her immediate possession or control or subject to his or her immediate possession or control to the sheriff of the county having jurisdiction of this proceeding, to his or her lawyer or to a person designated by the court. 1.4 Other Temporary Relief [] [] Does not apply. (Name(s))_________________________________________________________ also be required to appear and show cause why the court should not enter a temporary order which: [] grants the petitioner custody of the following children: [] grants visitation for respondent (name) _____________________________ as set forth in the attached proposed Residential Schedule, or as follows: [] grants visitation for respondent (name) ________________________________ as set forth in the attached proposed Residential Schedule, or as follows: Mtn/Decl for Ex Parte Restraining Ord (MTSC) - Page 2 of 6 WPF CU 03.0150 Mandatory (6/2008) - CR 65 (b); RCW 26.10.115 American LegalNet, Inc. www.FormsWorkflow.com [] [] [] 1.5 orders child support as determined pursuant to the Washington State child support statutes. orders him or her to pay temporary attorney fees, other professional fees and costs in the amount of $_______________ to: Other: Indian Child Welfare Act The requesting party requests that the court enter an order finding that: Indian Child Status: [] [] The child(ren) are Indian child(ren) as defined by the Indian Child Welfare Act, 25 USC § 1903, and notice of this action must be given in accordance with 25 U.S.C. § 1912(a). None of the child(ren) are Indian child(ren) as defined by 25 U.S.C. § 1903. Jurisdiction: [] [] 1.6 The child(ren) are Indian child(ren) as defined by the Indian Child Welfare Act, 25 USC § 1903, but are not domiciled or residing within the boundaries of an Indian reservation; and no Tribal Court has continuing jurisdiction over the child(ren); this court has jurisdiction under 25 USC § 1911. The child(ren) are Indian child(ren) as defined by the Indian Child Welfare Act, 25 USC § 1903, and are domiciled or residing within the boundaries of an Indian reservation; or a Tribal Court has continuing jurisdiction over the child(ren). Other Date Signature of Requesting Party or Lawyer/WSBA No. Print or Type Name Date [ ] Guardian Ad Litem Signature of Requesting Party or Lawyer/WSBA No. Print or Type Name Mtn/Decl for Ex Parte Restraining Ord (MTSC) - Page 3 of 6 WPF CU 03.0150 Mandatory (6/2008) - CR 65 (b); RCW 26.10.115 American LegalNet, Inc. www.FormsWorkflow.com Date Signature of Guardian ad Litem or Lawyer/WSBA No. Print or Type Name II. Declaration 2.1 Injury to be Prevented The ex parte restraining order requested in paragraph 1.1 above is to prevent the following injury (define the injury): 2.2 Reasons for Other Ex Parte Relief [] [] 2.3 Does not apply. It is necessary that the court issue the other ex parte relief requested in paragraph 1.2 above for the reason set forth below: Reasons why the Injury May Be Irreparable This injury may be irreparable because: Mtn/Decl for Ex Parte Restraining Ord (MTSC) - Page 4 of 6 WPF CU 03.0150 Mandatory (6/2008) - CR 65 (b); RCW 26.10.115 American LegalNet, Inc. www.FormsWorkflow.com 2.4 Clear and Convincing Reasons Why Weapons Should Be Surrendered [] [] 2.5 Reasons for a Temporary Order [] [] 2.6 Does not apply. (Name) _______________________________ should be required to surrender any deadly weapons as requested in paragraph 1.3 above because of following clear and convincing reasons: Does not apply. It is necessary that the court issue a temporary order with the relief requested in paragraph 1.4 above for the following reasons: Service Member or Dependant of Service Member [] If the other party is not present and: a) is on active duty and is a National Guard member or Reservist residing in Washington, or b) is a dependent of a National Guard member or Reservist residing in Washington on active Mtn/Decl for Ex Parte Restraining Ord (MTSC) - Page 5 of 6 WPF CU 03.0150 Mandatory (6/2008) - CR 65 (b); RCW 26.10.115 American LegalNet, Inc. www.FormsWorkflow.com duty, list the reasons why this temporary order should be granted despite the absence of the other party: I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at (city) ________________________, (state) __________ on (date) ___________________. Signature of Requesting Party Print or Type Name Do not attach financial records, personal health care records or confidential reports to this declaration. Such records should be served on the other party and filed with the court using one of these cover sheets: 1) Sealed Financial Source Documents (WPF DRPSCU 09.0220) for financial records 2) Sealed Personal Health Care Records (WPF DRPSCU 09.0260) for health records 3) Sealed Confidential Report (WPF DRPSCU 09.270) for confidential reports If filed separately using a cover sheet, the records will be sealed to protect your privacy (although they will be available to all parties in the case, their attorneys, court personnel and certain state agencies and boards.) See GR 22(C)(2). III. Efforts to Give Other Party Notice The following efforts have been made to give the other party or other party's lawyer notice and the following reasons exist why notice should not be required: Dated: Signature of Requesting Party or Lawyer/WSBA No. Print or Type Name Mtn/Decl for Ex Parte Restraining Ord (MTSC) - Page 6 of 6 WPF CU 03.0150 Mandatory (6/2008) - CR 65 (b); RCW 26.10.115 American LegalNet, Inc. www.FormsWorkflow.com