Court of Washington For No. Petitioner vs. Respondent 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 child in common current or former domestic partner current or former cohabitant as part of a dating relationship 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 1. Petition for Order for Protection (PTORPRT) Petition for Order for Protection (PTORPRT) - Page 1 of 7 WPF DV-1.015 Mandatory (06/2014) - 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 I Request an Order for Protection following a hearing that will: 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, current or former domestic partner, the parent of a child in common, or a current or former cohabitant as part of a dating relationship, the respondent will not be able to obtain or possess a firearm, other dangerous weapon, ammunition, or concealed pistol license under state or federal law for the duration of the order.) 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: 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: Petition for Order for Protection (PTORPRT) - Page 2 of 7 WPF DV-1.015 Mandatory (06/2014) - RCW 26.50.030 American LegalNet, Inc. www.FormsWorkFlow.com 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: other: the minors You have a right to keep your residential address confidential. 5 6 Direct respondent to vacate our shared residence and restore it to me. 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. Other: 9 Protection involving a minor: 10 Subject to any court-ordered visitation, Grant me the care, custody and control of minors named in paragraph 5 above these minors only: the 11 Restrain respondent from interfering with my physical or legal custody of named in paragraph 5 above these minors only: the minors 12 Restrain the respondent from removing from the state: paragraph 5 above these minors only: the minors named in Additional Requests: 13 14 15 Direct the respondent to participate in appropriate treatment or counseling services. Require the respondent to pay the fees and costs of this action. 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. Petition for Order for Protection (PTORPRT) - Page 3 of 7 WPF DV-1.015 Mandatory (06/2014) - RCW 26.50.030 American LegalNet, Inc. www.FormsWorkFlow.com Protection involving pets. 16 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.): ____________________________________________________________. Prohibit respondent from interfering with my efforts to remove the pet(s) named above. 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:______________________________________________________ 17 18 Protection from Firearms and Other Dangerous Weapons 19 Require the respondent to surrender any firearm or other dangerous weapon, or any concealed pistol license, and prohibit the respondent from obtaining or possessing a firearm or other dangerous weapon, or a concealed pistol license. Notice: If you are the respondent's intimate partner, after actual notice and an opportunity to be heard at the hearing, the court may be required to order the respondent to surrender firearms, other dangerous weapons, or concealed pistol license. I want emergency temporary protection effective immediately, that lasts (up to 14 days) until the court hearing: An emergency exists as described below. I request that a Temporary Order for Protect