Dating Violence Ex Parte Protective Order

Authored By: Supreme Court of Georgia

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SC-29 Dating Violence Ex Parte Protective Order                                     ORI Number ____________________ 





Petitioner,                                                                                                          Civil Action File

v.                                                                                                                       No._______________________





Petitioner having prayed pursuant to O.C.G.A. § 19-13A-1 et seq., that a Protective Order be issued; and alleged that Respondent has committed acts of Dating Violence; and the Court finds that probable  cause exists to establish that the parties are currently, or within the last six months were, in a dating  relationship or that a party to this action is currently pregnant with the other party’s child (check all that  apply). 

_____ a. There is a committed romantic relationship between the parties that is more intimate than  what is associated with mere friendship or ordinary business, social, or educational  fraternization; 

_____ b. Factors exist which corroborate the dating relationship; 

_____ c. The parties developed interpersonal bonding above a mere casual fraternization;

_____ d. The length of the relationship between the parties is indicative of a dating relationship; 

_____ e. The nature and frequency of the parties’ interactions, including communications, indicate  the parties intended to be in a dating relationship; 

_____ f. The parties by statement or conduct demonstrated an affirmation of their relationship to  others; 

_____ g. Both parties have acknowledged the dating relationship; or, 

_____ h. A party to this action is currently pregnant with the other party’s child. 

The Court relied on the following specific facts in finding the above:






The Court further finds that probable cause exists that the following act(s) of Dating Violence has/have occurred in the past and may occur in the future: 

_______ Simple battery (O.C.G.A. § 16-5-23) 

_______ Battery (O.C.G.A. § 16-5-23.1) 

_______ Simple assault (O.C.G.A. § 16-5-20) 

_______ Stalking (O.C.G.A. § 16-5-90) 

_______ The felony offense(s) of ________________________________________________________ 



1. That these proceedings be filed in the office of the Clerk of this Court.  

2. That this Order applies in every county throughout the state and it shall be the duty of  every court and every law enforcement official to enforce and carry out the provisions of  this Order pursuant to O.C.G.A. § 19-13A-4. Law enforcement officers may use their  arrest powers pursuant to O.C.G.A. §§ 19-13A-6 and 17-4-20 to enforce the terms of this  Order. 

3. That a copy of this Order be given to law enforcement and Respondent be served with a  copy of this Order and Petition for Temporary Protective Order instanter.  

4. That Respondent appear before this Court, on the _____ day of  _____________________, 20_____ at __________.m. in room __________ of the  __________________ County Courthouse at _____________________________ to show cause why the requests of Petitioner should not be granted.  

5. That Respondent is hereby enjoined and restrained from doing, or attempting to do, or threatening to do, any act of injury, maltreating, molesting, following, harassing, harming  or abusing Petitioner in any manner. Respondent is not to interfere with Petitioner’s travel,  transportation, or communication. Respondent shall not follow, place under surveillance,  or contact Petitioner at any place of Petitioner for the purpose of harassing and intimidating  Petitioner. 

6. That this Court determined that it had jurisdiction over the parties and the subject matter  under the laws of the State of Georgia and the Court ordered that Respondent be given  reasonable notice and opportunity to be heard sufficient to protect Respondent’s due  process rights. This Order shall be presumed valid and pursuant to 18 U.S.C. § 2265 (a)  shall be accorded full faith and credit by any other state or local jurisdiction and shall be  enforced as if an Order of the enforcing state or jurisdiction. 



_____ 7. Respondent is ordered to permit Petitioner to enter Respondent’s residence to retrieve  Petitioner’s property and law enforcement ____________________ (sheriff or police  department) is ordered to assist Petitioner in returning to Respondent’s residence and  retrieving Petitioner’s property. 

_____ 8. Respondent is to immediately surrender to law enforcement _________________ (sheriff  or police department) all and any keys, garage door openers and other security devices to  Petitioner’s residence and law enforcement is to ensure that these are given to Petitioner. 

_____ 9. Petitioner’s address is ordered to be kept confidential. 

_____ 10. Respondent is ordered to stay away from Petitioner’s residence at _______________________________________________ and workplace at  _______________________________________________ and _______________________________________________ school and any subsequent  residence or workplace or school of Petitioner.  

_____ 11. That until further Order of this Court, Respondent is restrained and enjoined from approaching within ________ yards of Petitioner.  

_____ 12. Respondent is ordered not to have any contact, direct, indirect or through another person, with Petitioner, by telephone, fax, e-mail, electronic media or any other means of  communication except as specified in this Order. 

_____ 13. That Respondent, only when accompanied by local law enforcement, shall be able to  remove his/her clothing and personal items from Petitioner’s residence as  follows:________________________________________________________________  ______________________________________________________________________ 

____________________________________________________________________ on  ______________________________, 20____ at ____.m. 

_____ 14. Respondent is ordered not to interfere with Petitioner including that Respondent may not  sell, encumber, trade, damage, contract to sell, or otherwise dispose of or remove from  the jurisdiction of this court any of the property of Petitioner.  

_____ 15. That Petitioner shall be allowed to remove the following property from Respondent’s  residence for Petitioner’s use: 


on ________________________________, 20 ____ at _______ .m. law enforcement  _________________ (sheriff or police department) is hereby ordered to assist Petitioner  during this removal.  

_____ 16. That Respondent shall be required to return the following property for Petitioner’s  use:___________________________________________________________________ ______________________________________________________________________ __________________________________________________________________ and  on ________________________________, 20 ____ at _______ .m. law enforcement  _________________ (sheriff or police department, is hereby ordered to assist Petitioner  during this return. 

_____ 17. It is further Ordered:





SO ORDERED this_______ day of ____________________, 20_____. 


________________________ County 



Print or stamp Judge’s name 

Violation of the above Order may be punishable by arrest.


CIVIL ACTION FILE NO.  ________________________


1. Violation of this Order may result in immediate arrest and criminal prosecution that  may result in jail time and/or fines and/or may subject you to prosecution and penalties  for contempt of court.  

2. This Order shall remain in effect unless specifically superseded by a subsequent signed  and filed Order, by operation of law, or by Order of dismissal, whichever occurs first.  Only this Court can void, modify or dismiss this Order. Either party may ask this  Court to change or dismiss this Order.  

3. A person commits the offense of Aggravated Stalking when such person, in violation of  a temporary or permanent protective Order prohibiting this behavior, follows, places  under surveillance, or contacts Petitioner on public or private property for the purpose  of harassing and intimidating the other person. This activity can subject Respondent  to arrest and prosecution for felony Aggravated Stalking, which carries penalties of  imprisonment for not less than 1 year nor more than 10 years and a fine of up to  $10,000.00.

CIVIL ACTION FILE NO. _______________________

Pursuant to O.C.G.A. § 19-13A-3, Petitioner assisted by 

Name: ________________________

Address: ______________________


Telephone: ____________________

CIVIL ACTION FILE NO. _______________________


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.

*For transmittal to the Georgia Protective Order Registry and, if applicable, the National Crime Information Center.* 


(please complete as much as possible; one of these must be provided to have the order placed in the National  Crime Information 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:  ____________________________________.



Petitioner: ___________________________ DOB ___________ sex _______ race ______________

Other: ___________________________ DOB ___________ sex _______ race ______________

Other: ___________________________ DOB ___________ sex _______ race ______________

Other: ___________________________ DOB ___________ sex _______ race ______________

Other: ___________________________ DOB ___________ sex _______ race ______________


 Transmitted to Georgia Protective Order Registry Date __________ Clerk _________________________ Rev’d 1/22 

Last Review and Update: Feb 15, 2022
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