Dating Violence Twelve Month Protective Order

Authored By: Supreme Court of Georgia

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SC-30 Dating Violence Twelve Month Protective Order 

ORI Number ____________________ 

THE SUPERIOR COURT FOR THE COUNTY OF ________________________ 



Petitioner,                                                                                                                                        Civil Action File 


v.                                                                                                                                                        No. _________________________ 






A hearing was held on this matter on ___________________________, 20_____ for which  Respondent had notice as required by law and at which Respondent appeared and/or was provided with  the opportunity to be heard and Petitioner requested that the Protective Order entered in this case be  continued. Having heard the evidence presented, reviewed the petition and the entire record concerning  this case and for good cause shown, the court FINDS 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: 

FINDINGS OF FACT/S – At least one of the following is found as initialed by the Judge: 

_____ a. There is a committed romantic relationship between the parties that is not 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 (e). Law enforcement may use their arrest powers pursuant to O.C.G.A. § 17-4-20 to enforce the terms of this Order. 

3. This Order shall remain in effect for up to twelve (12) months from this date ______________________, 20____ until ______________________, 20____. 

4. Respondent has violated the Dating Violence Act, O.C.G.A. § 19-13A-1 et seq. by committing dating violence, and represents a credible threat to the physical safety of  Petitioner. 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 the petitioner at any place of Petitioner for the purpose of  harassing and intimidating Petitioner. 

5. 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 ordered as if an Order of the enforcing state or jurisdiction. 



_____ 6. 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. 

_____ 7. Respondent shall 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 shall ensure that these are given  to Petitioner. 

_____ 8. Petitioner’s address is ordered to be kept confidential. 

_____ 9. 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. 

_____ 10. That Respondent is restrained and enjoined from approaching within ____________  yards of Petitioner. 

_____ 11. 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. 

_____ 12. 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. 

_____ 13. 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. 

_____ 14. That Petitioner shall be allowed to remove the following property from Respondent’s  residence for Petitioner’s use: ___________________________________ _____________________________________________________________________ _____________________________________________________________________ __________________________________________________________________ and on _________________________________, 20 ____ at _______ .m. law  enforcement _________________ (sheriff or police department) is hereby ordered to  assist Petitioner during this removal. 

_____ 15. 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. 

_____ 16. Respondent is ordered to undergo appropriate psychiatric, psychological, or  educational services (initial all that apply): 

_____ Respondent is ordered to undergo evaluation for drug/alcohol abuse and to  follow the recommended treatment. 

_____ Respondent is ordered to undergo psychiatric/psychological/mental health evaluation and to follow the recommended treatment. 


_____ It is further Ordered that Respondent shall make arrangements to begin a  Georgia Commission on Family Violence (GCFV) certified family violence intervention program (FVIP) within fourteen (14) days of the signing of this Order, or if appropriate within fourteen (14) days upon release from incarceration. A list of local certified agencies can be found at Furthermore, Respondent shall appear before this court __________________________, 20____ at __________.m. for a hearing on the status of his/her application, attendance and/or completion of the FVIP. At that hearing, Respondent is ordered to present to this court a written status report from the agency providing the certified FVIP. The status report shall detail Respondent’s application, attendance and/or completion of or failure to apply, attend and/or complete the FVIP and shall be signed by an officer of the agency. 

_____ 17. Petitioner is awarded costs and attorney fees in the amount of $________________. _____ 18. Respondent is awarded attorney fees in the amount of $________________. _____ 19. 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, follow, 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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