CH-100
Request for Civil Harassment
Restraining Orders
Clerk stamps date here when form is filed.
Fill in court name and street address:
Superior Court of California, County of
Court fills in case number when form is filed.
Case Number:
Read Can a Civil Harassment Restraining Order Help Me? (form CH-100-
INFO) before completing this form. Also fill out Confidential CLETS
Information (form CLETS-001) with as much information as you know.
Person Seeking Protection
a.
Your Full Name:
Age:
Your Lawyer (if you have one for this case)
Name: State Bar No.:
Firm Name:
b.
Your Address (If you have a lawyer, give your lawyer’s
information. If you do not have a lawyer and want to keep your
home address private, you may give a different mailing address
instead. You do not have to give telephone, fax, or e-mail.)
Address:
City: State: Zip:
Telephone: Fax:
E-Mail Address:
2
Person From Whom Protection Is Sought
Full Name: Age:
Address (if known):
City: State: Zip:
3
Additional Protected Persons
a. Are you asking for protection for any other family or household members?
Yes
No
If yes, list them:
Full Name Sex Age Lives with you? How are they related to you?
Yes
No
Yes
No
Yes
No
Yes
No
Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of
paper or form MC-025 and write “Attachment 3b—Why Others Need Protection” for a title.
Check here if there are more persons. Attach a sheet of paper and write “Attachment 3a—Additional Protected
Persons” for a title. You may use form MC-025, Attachment.
b. Why do these people need protection? (Explain below):
This is not a Court Order.
Judicial Council of California, www.courts.ca.gov
Revised January 1, 2018, Mandatory Form
Code of Civil Procedure, §§ 527.6 and 527.9
Request for Civil Harassment Restraining Orders
(Civil Harassment Prevention)
CH-100, Page 1 of 6
1
4
2
Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of
paper or form MC-025 and write “Attachment 4—Relationship of Parties” for a title.
5
The person in lives in this county.
I was harassed by the person in in this county.
Other (specify):
2
2
6
3
2
3
2
7
Description of Harassment
Harassment means violence or threats of violence against you, or a course of conduct that seriously alarmed,
annoyed, or harassed you and caused you substantial emotional distress. A course of conduct is more than one act.
a.
Tell the court about the last time the person in harassed you.
2
(1)
When did it happen? (provide date or estimated date):
(2)
Who else was there?
b.
Are there now any protective or restraining orders in effect relating to you or any of the persons in and the
person in ?
Other Court Cases
a.
Have you or any of the persons named in been involved in another court case with the person in ?
How do you know the person in ? (Explain below):
Relationship of Parties
Why are you filing in this county? (Check all that apply):
b.
c.
a.
Venue
(If yes, attach a copy if you have one.)
Yes
No
This is not a Court Order.
Revised January 1, 2018
Request for Civil Harassment Restraining Orders
(Civil Harassment Prevention)
CH-100, Page 2 of 6
(1)
Civil Harassment
Domestic Violence
Divorce, Nullity, Legal Separation
Paternity, Parentage, Child Custody
Elder or Dependent Adult Abuse
Eviction
Guardianship
Workplace Violence
Small Claims
Criminal
Other (specify):
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
Kind of Case Filed in (County/State)
(If yes, check each kind of case and indicate where and when each was filed.)
Yes No
Year Filed
Case Number (if known)
Case Number:
(3)
How did the person in harass you? (Explain below):
2
Check here if there is not enough space for your answer. Put your complete answer on the attached
sheet of paper or form MC-025 and write “Attachment 7a(3)—Describe Harassment” for a title.
(4) Did the person in use or threaten to use a gun or any other weapon?
2
(If yes, explain below):
NoYes
Check here if there is not enough space for your answer. Put your complete answer on the attached
sheet of paper or form MC-025 and write “Attachment 7a(4)—Use of Weapons” for a title.
(5)
Were you harmed or injured because of the harassment?
(If yes, explain below):
Yes
No
Check here if there is not enough space for your answer. Put your complete answer on the attached
sheet of paper or form MC-025 and write “Attachment 7a(5)—Harm or Injury” for a title.
Did the police come?
Yes
No
If yes, did they give you or the person in an Emergency Protective Order?
2
Yes
No
If yes, the order protects (check all that apply):
Me
The person in
2
The persons in
3 .
(Attach a copy of the order if you have one.)
b. Has the person in harassed you at other times?
2
Yes No (If yes, describe prior incidents and provide dates of harassment below):
Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of
paper or form MC-025 and write “Attachment 7b—Previous Harassment” for a title.
This is not a Court Order.
Revised January 1, 2018
Request for Civil Harassment Restraining Orders
(Civil Harassment Prevention)
CH-100, Page 3 of 6
(6)
Case Number:
7
a.
8
Personal Conduct Orders
Harass, intimidate, molest, attack, strike, stalk, threaten, assault (sexually or otherwise), hit, abuse, destroy
personal property of, or disturb the peace of the person.
Contact the person, either directly or indirectly, in any way, including, but not limited to, in person, by
telephone, in writing, by public or private mail, by interoffice mail, by e-mail, by text message, by fax, or by
other electronic means.
Other (specify):
Check here if there is not enough space for your answer. Put your complete answer on the attached
sheet of paper or form MC-025 and write “Attachment 8c—Other Personal Conduct Orders,” for a
title.
9
10
Yes No I don’t know
If the judge grants a protective order, the person in will be prohibited from owning, possessing, purchasing,
receiving, or attempting to purchase or receive a gun, other firearm, and ammunition while the protective order
is in effect. The person in will also be ordered to turn in to law enforcement, or sell to or store with a
licensed gun dealer, any guns or firearms within his or her immediate possession or control.
Does the person in own or possess any guns or other firearms?
Check the orders you want.
þ
c.
I ask the court to order the person in not to do any of the following things to me or to any person to be
protected listed in :
a.
b.
The person in will be ordered not to take any action to get the addresses or locations of any protected person
unless the court finds good cause not to make the order.
Guns or Other Firearms and Ammunition
Request for Civil Harassment Restraining Orders
(Civil Harassment Prevention)
CH-100, Page 4 of 6
This is not a Court Order.
2
3
2
2
2
2
I ask the court to order the person in to stay at least yards away from (check all that apply):
Me.
The other persons listed in .
3
My home.
My job or workplace.
My school.
My children’s school.
My children’s place of child care.
My vehicle.
Other (specify):
If the court orders the person in to stay away from all the places listed above, will he or she still be able
to get to his or her home, school, or job?
(If no, explain below):
b.
a.
(3)
(4)
(5)
(6)
(8)
(9)
(1)
(2)
(7)
2
2
Yes No
Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of
paper or form MC-025 and write “Attachment 9b—Stay-Away Orders,” for a title.
Stay-Away Orders
Case Number:
Revised January 1, 2018
Has the person in been told that you were going to go to court to seek a TRO against him/her?
11
Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of
paper or form MC-025 and write “Attachment 11—Temporary Restraining Order” for a title.
2
12
Request to Give Less Than Five Days' Notice of Hearing
2
Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of
paper or form MC-025 and write “Attachment 12—Request to Give Less Than Five Days’ Notice” for a title.
13
No Fee for Filing or Service
There should be no filing fee and the sheriff or marshal should serve the person in for free because I
am entitled to a fee waiver. (You must complete and file form FW-001, Application for Waiver of Court
Fees and Costs .)
The sheriff or marshal should serve (notify) the person in about the orders for free because my request
for orders is based on unlawful violence, a credible threat of violence, or stalking.
There should be no filing fee because the person in has used or threatened to use violence against me,
has stalked me, or has acted or spoken in some other way that makes me reasonably fear violence.
2
2
2
14
Lawyer's Fees and Costs
lawyer’s fees
Court costs.
$ $
$ $
$ $
Check here if there are more items. Put the items and amounts on the attached sheet of paper or form
MC-025 and write “Attachment 14—Lawyer’s Fees and Costs” for a title.
You must have your papers personally served on the person in at least five days before the hearing, unless the
court orders a shorter time for service. (Form CH-200-INFO explains What Is “Proof of Personal Service”? Form
CH-200, Proof of Personal Service, may be used to show the court that the papers have been served.)
(If you answered no, explain why below):
a.
b.
c.
If you want there to be fewer than five days between service and the hearing, explain why below:
I ask the court to order payment of my
Item Amount Item Amount
Request for Civil Harassment Restraining Orders
(Civil Harassment Prevention)
CH-100, Page 5 of 6
This is not a Court Order.
Yes
No
The amounts requested are:
Case Number:
Revised January 1, 2018
Temporary Restraining Order
I request that a Temporary Restraining Order (TRO) be issued against the person in to last until the hearing. I
am presenting form CH-110, Temporary Restraining Order, for the court’s signature together with this Request.
2
15
Possession and Protection of Animals
17
Number of pages attached to this form, if any:
Date:
Lawyer’s name (if any)
Lawyer’s signature
Sign your name
I declare under penalty of perjury under the laws of the State of California that the information above and on all
attachments is true and correct.
I ask the court to order the following:
Request for Civil Harassment Restraining Orders
(Civil Harassment Prevention)
CH-100, Page 6 of 6
This is not a Court Order.
Date:
Type or print your name
Case Number:
a. That I be given the sole possession, care, and control of the animals listed below, which I own, possess,
lease, keep, or hold, or which reside in my household.
(Identify animals by, e.g., type, breed, name, color, sex.)
b.
That the person in must stay at least yards away from, and not take, sell, transfer, encumber,
conceal, molest, attack, strike, threaten, harm, or otherwise dispose of, the animals listed above.
2
Revised January 1, 2018
Check here if there is not enough space for your answer. Put your complete answer on the attached
sheet of paper or form MC-025 and write “Attachment 15a—Possession of Animals” for a title.
I request sole possession of the animals because (specify good cause for granting order):
16
Additional Orders Requested
I ask the court to make the following additional orders (specify):
Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of
paper or form MC-025 and write “Attachment 16—Additional Orders Requested,” for a title.
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