Petition for Dating Violence Temporary Protective Order
HTML version of Petition
SC-28 Petition for Dating Violence Temporary Protective Order
THE SUPERIOR COURT FOR THE COUNTY OF ________________________
STATE OF GEORGIA
______________________,
Petitioner, Civil Action File
v. No. _________________________
______________________,
Respondent.
PETITION FOR DATING VIOLENCE TEMPORARY PROTECTIVE ORDER
Petitioner, pursuant to O.C.G.A. § 19-13A-1 et seq., files this Petition for a Dating Violence Temporary Protective Order and in support shows the Court the following:
1. Petitioner is a resident of _____________________ County, Georgia. Petitioner is over the age of 18.
2. Respondent is a resident of ___________________ County, Georgia, and may be served at , ________________________________________________________________Georgia. Jurisdiction and venue are proper with this Court.
OR
2.1 Respondent is a resident of the State of . Under O.C.G.A. §19-13A-2 (b), jurisdiction and venue are proper with this Court because the abuse occurred in the State of Georgia in ________________ County and/or Petitioner lives in ____________________ County. Respondent is subject to the jurisdiction of this Court and may be served at _________________________________________________________________________________________________________________
3. Petitioner and Respondent are currently, or within the last six months were, in a dating relationship as described by O.C.G.A. § 19-13A-1 (check all that apply):
[ ] Yes [ ] No Is either party pregnant with the other party’s child?
[ ] Yes [ ] No Are you currently in a committed romantic relationship with Respondent?
[ ] Yes [ ] No If you and Respondent are not currently in a committed romantic relationship, were you in a committed romantic relationship within the last six (6) months?
Please describe what makes your relationship with the Respondent a romantic or dating relationship, including (1) how long you have dated, (2) how you spend time together, (3) how often you communicate and see each other, (4) how you have represented the relationship to others (such as on social media), and (5) whether you are physically intimate with each other (i.e. do you hold hands, kiss, have sex, sleep together, etc.):
4. On or about _________________________, 20___, Respondent committed the following acts of Dating Violence (simple battery, battery, simple assault, stalking, any felony) against Petitioner (please describe):
and Petitioner is in reasonable fear for Petitioner’s own safety.
5. At other times Respondent has committed other such acts/crimes against Petitioner, including but not limited to (approximate dates and what happened):
6. There is a substantial likelihood that Respondent will commit such acts of violence against Petitioner in the immediate future if relief is not granted as provided pursuant to O.C.G.A. § 19-13A-4. Check the paragraphs below that apply to your case. Fill in the information needed by each paragraph you check.
7. Petitioner fears that if Respondent learns of Petitioner's current address that Respondent will hurt or injure Petitioner. Petitioner requests that Respondent not be informed of Petitioner's current residence.
8. Petitioner asks that the Court award possession of the following property to Petitioner (list items specifically including household goods, keys, pets):
THEREFORE, Petitioner asks:
(a) That the Court set a hearing no later than thirty (30) days from the filing of the Petition and direct Respondent to appear before this Court and show any reasons why the demands of Petitioner should not be granted;
(b) That Respondent be served a copy of this Petition and Ex Parte Protective Order as required by law;
(c) That this Court direct law enforcement to enforce this Order;
(d) That this Court direct Respondent to stop abusing, harassing and intimidating Petitioner;
(e) That this Court restrain and enjoin Respondent from having any direct or indirect contact with Petitioner;
(f) That this Court order that Respondent be enjoined from approaching within _______ yards of Petitioner;
(g) That this Court make findings of fact and conclusions of law concerning the issues in this case;
(h) That Petitioner have such other and further relief as the Court may deem just and proper;
(i) That this Court issue Dating Violence Ex Parte and Twelve Month Protective Orders to: ________________________________________________________
Check the paragraphs below that apply to your case. Fill in the information needed by each paragraph you check.
order Respondent to stay away from Petitioner’s place of residence, place of employment, and/or school, as well as return any and all keys, garage door openers, and other security and access devices to Petitioner;
____ award Petitioner costs and attorney’s fees for having to bring this action; order that Petitioner’s current address be kept confidential;
____ enjoin and restrain Respondent from selling, disposing or encumbering, trading, contracting to sell, or otherwise disposing or removing from the jurisdiction of this Court any of the property of Petitioner or of the parties except in the ordinary course of business;
____ permit Petitioner to remove the following property of Petitioner’s from Respondent’s residence for the exclusive use by Petitioner
and law enforcement (sheriff or police department) be ordered to assist Petitioner during this removal;
_____ order Respondent to undergo appropriate psychiatric, psychological, or educational services (i.e., an appropriate intervention program);
_____ order Respondent to undergo evaluation for drug/alcohol abuse and to follow the recommended treatment;
_____ order Respondent to return the following property: _____________________________________________________________________ to Petitioner immediately;
_____ order additional relief as follows:
Respectfully submitted,
___________________________________
Petitioner’s Signature
Petitioner’s Address
___________________________________
___________________________________
___________________________________
Telephone: __________________________
(Do not give current address if confidential; give alternative address)
CIVIL ACTION FILE NO. _________________
THE SUPERIOR COURT FOR THE COUNTY OF ________________________
STATE OF GEORGIA
______________________,
Petitioner, Civil Action File
v. No. _________________________
______________________,
Respondent.
VERIFICATION
Personally appeared _______________________________________, who being duly sworn states that she/he is the Petitioner in the above styled case and that the facts set forth in the foregoing Petition are true and correct.
___________________________
Petitioner
Sworn and subscribed before
me this__________ day of____________ , 20__ .
___________________________________________
NOTARY PUBLIC/JUDGE/CLERK
My commission expires:
CIVIL ACTION FILE NO.__________________________
Pursuant to O.C.G.A. § 19-13A-3,
Petitioner assisted by
Name: _______________________________
Address: _____________________________
_____________________________________
Phone: _______________________________
CIVIL ACTION FILE NO. _________________
*REMOVE THIS PAGE FROM ORDER AND FILE SEPARATELY UNDER SEAL*
CONFIDENTIAL INFORMATION FORM - ATTENTION COURT STAFF: THIS PAGE IS A RESTRICTED-ACCESS DOCUMENT. This document is not accessible to the public or to other parties.
RESPONDENT’S IDENTIFYING FACT SHEET
(please complete as much as possible; one of these must be provided to have the order placed in the National CrimeInformation Center registry: Respondent’s date of birth OR social security number)
Respondent’s social security number is __________________, date of birth is ________________, sex_______, color of hair_______________ , color of eyes____________ , height __________, weight ________. Respondent’s race is____________________________ , ethnic background ______________________. Respondent has distinguishing marks (tattoos, scars, etc.)_____________________________________ . Respondent drives a______________________ , license tag no: ____________________ (Expires:______________ ) and has a (state) driver’s license no:_____________________ (Expires:________________ ). Respondent’s home address is _________________________________________________________________and is employed by___________________________ at________________________________________________________ and works from____ to_______ on__________________________________________ (days) . Respondent has the following known aliases: _________________________________________________________________.
PROTECTED PARTIES’ IDENTIFYING INFORMATION
Petitioner: ________________________________ DOB______________________ sex________________ race____________________
Other: ________________________________ DOB______________________ sex________________ race____________________
Other: ________________________________ DOB______________________ sex________________ race____________________
Other: ________________________________ DOB______________________ sex________________ race____________________
Other: ________________________________ DOB______________________ sex________________ race____________________