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FORM DV1: Application for a Protection Order (Department of the Environment and Energy)

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Domestic and Family Violence Protection Act 2012
Form DV1 – version 3 – 25 November 2017 Page 1 of 1
FORM DV1
Domestic and Family Violence Protection Act 2012 (s.32)
Application for a Protection Order
Please note: A copy of this application will be provided to the aggrieved, applicant, respondent and police
1. Aggrieved’s details
If the aggrieved does not want the respondent to know their home address please either:
Give an address where court documents can be sent e.g. post office box or
Complete an “Aggrieved Details Form” which will not be provided to the respondent
Given Name/s Family Name Date of birth
/
/
Address *Leave blank if you do not want this information to be given to the other party
Gender Home Number Mobile Number
Work Phone Email SPI # (QPS Only)
Does the aggrieved require an interpreter? No Yes Language/Dialect:
Does the aggrieved identify as: Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander Neither
Does the aggrieved have a disability, illness or impairment where support and/or special arrangements are required? No Yes
Is the aggrieved under 18 years of age? No Yes
Please supply the details of a parent as all documents must be given to a parent of the aggrieved unless the court orders otherwise.
Parent’s Name
Parent’s Address
Proceed to Question 2
2. Respondent’s Details
Given Name/s Family Name Date of birth
/
/
Address
Gender Home Number Mobile Number
Work Phone Email SPI # (QPS Only)
Does the respondent require an interpreter? No Yes Language/Dialect:
Does the respondent identify as: Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander Neither
Page 2 of 8
Does the respondent have a disability, illness or impairment where support and/or special arrangements are required? No Yes
Current place of employment Vehicle Model: Vehicle Registration
Is the respondent under 18 years of age? No Yes
Please supply the details of a parent as all documents must be given to a parent of the respondent unless the court orders otherwise.
Parent’s Name
Parent’s Address
If you are the aggrieved, proceed to Question 4
If you are NOT the aggrieved proceed to Question 3
3. Applicant’s Details
This section only applies if a person other than the aggrieved is making the application. Please complete either Part A, B, C or D.
PART A – A person being authorised by the Aggrieved
Given Name/s Family Name Gender
Address
Is the authorisation of the aggrieved in writing? No Yes
If the authorisation is not in writing, how is authorisation communicated from the aggrieved?
PART B – A person acting under another Act for the Aggrieved
Name Gender
Address
Who is the application being made by? A guardian Adult Guardian Enduring power of attorney
Other, please specify:
PART C – A Police Officer
Full Name including Rank: Registration #
Station Police Occurrence #
Has the aggrieved been advised of this application? No Yes
Has the application resulted from the detention of the respondent? No Yes
Is this an application for an urgent temporary protection order under section 130? No Yes
If yes, has an application for a domestic violence order already been made? No Yes Court File Number:
Domestic and Family Violence Protection Act
2012
Form DV1 – version 3 – 25 November 2017
Page 3 of 8
PART D – A party to a child protection proceeding
Given Name/s Family Name Gender
Address
What type of party to a child protection proceeding are you?
A child for whom an order is sought in a child protection proceeding
A separate legal representative for a child for whom an order is sought in a child protection proceeding
An applicant or respondent in a child protection proceeding
Proceed to Question 4
4. Temporary Protection Order
Do you wish the court to make a temporary protection order? No Yes
If you request a temporary protection order before the respondent has been given a copy of the application, you will have to show the court
that there are reasons why it is necessary or desirable for you or a named person to be protected by a temporary protection order before
the respondent is given a copy of the application.
Please state reasons below:
Proceed to Question 5
5. Relationships between the aggrieved and the respondent
What is the relationship of the aggrieved to the respondent?
Intimate Personal Relationship – Please tick one
a) Spousal Relationship: Married Former Spouse De Facto Civil Partnership
Parent/Former Parent of a Child
b) Engaged Were Engaged
c) Couple State the nature of the relationship including the level of dependency on each other whether financial or otherwise;
length of time of the relationship; frequency of contact and degree of intimacy, if any.
Family Relationship
Relation to respondent (for example parent, sibling, aunt, cousin, stepchild, a person is regarded as a relative)
Domestic and Family Violence Protection Act 2012
Form DV1 – version 3 – 25 November 2017
Page 4 of 8
Informal Care Relationship
Nature of relationship
Proceed to Question 6
6. Grounds for a protection order
State grounds as to why a protection order is necessary or desirable to protect the aggrieved. It must be shown that domestic violence has
occurred. Include specific example of behaviour by the respondent. Attach extra pages if necessary
Proceed to Question 7
7. Children of the aggrieved or children who usually live with the aggrieved
Full Name of Child 1 Gender Date of birth
Address
Do you wish this child to be named on the order? No Yes SPI # (QPS Only)
Full Name of Child 2 Gender Date of birth
Address
Do you wish this child to be named on the order? No Yes SPI # (QPS Only)
/
/
/
/
Domestic and Family Violence Protection Act 2012
Form DV1 – version 3 – 25 November 2017
Page 5 of 8
Full Name of Child 3 Gender Date of birth
Address
Do you wish this child to be named on the order? No Yes SPI # (QPS Only)
State grounds as to why the child/children are to be named on the order
Proceed to Question 8
8. Relatives or associates you would like to be named on the order
Full Name of Relative Gender Date of birth
Address SPI # (QPS only)
Full Name of Relative Gender Date of birth
Address SPI # (QPS only)
Full Name of Associate Gender Date of birth
Address SPI # (QPS only)
Full Name of Associate Gender Date of birth
Address SPI # (QPS only)
State grounds as to why it is necessary or desirable to protect the relative/associate.
/
/
/
/
/
/
/
/
/
/
Domestic and Family Violence Protection Act 2012
Form DV1 – version 3 – 25 November 2017
Page 6 of 8
Proceed to Question 9
9. Weapons
Does the respondent have access to any weapons? No Yes
State the number, type of weapon/s and all possible locations of the weapon
Did the respondent use, or threaten to use, a weapon or another thing used as a weapon, during any incident of domestic violence?
No Yes Provide details
Has the respondent been issued with a weapons or firearms licence? No Yes
If the respondent has access to any weapons at their place of residence, please provide details
Proceed to Question 10
10. Details of any other orders
Has a court made any other order or are there other court proceedings that involve the aggrieved and the respondent? Please attach copies
Childrens Court orders Yes No
Queensland Domestic Violence Order Yes No
Police Protection Notice Yes No
Voluntary Intervention Order Yes No
Interstate Domestic Violence Order (including New Zealand) Yes No
Family Court Orders Yes No
Other relevant court order Yes No
Is there a current Protection Order application that has not been decided by the court? No Yes Attach a copy of the application
Proceed to Question 11
11. Conditions sought in the order
A court making a domestic violence order must impose a condition that the respondent –
Be of good behaviour towards the aggrieved and not commit domestic violence against the aggrieved.
If the order includes a named person who is an adult-
Be of good behaviour towards the named person and not commit associated domestic violence against the named person.
If the order includes a named person who is a child -
Be of good behaviour towards the child and not commit associated domestic violence against the child and not expose the child to domestic
violence.
A court may also impose any other condition that the court considers necessary in the circumstances and desirable in the interests of the
aggrieved, any named person or the respondent.
Do you want the court to consider any other conditions for inclusion in the protection order?
No Go to Q12 Yes Please indicate below
A) Do you want the respondent to leave specified premises? No Yes
If yes, state address of premises and provide reasons:
Domestic and Family Violence Protection Act 2012
Form DV1 – version 3 – 25 November 2017
Page 7 of 8
B) Do you want to prohibit the respondent from remaining at; entering or attempting to enter or approaching premises? No Yes
If yes, the premises to which the respondent is not to come or approach are:
The aggrieved’s place of residence The aggrieved’s place of employment The place the aggrieved is currently staying
Places where the aggrieved frequents, namely
Associates/relatives place of residence (if there is a named person at Question 8)
Give reasons
C) Do you want to prohibit the respondent approaching the aggrieved? No Yes
Does this include any associates or relatives (if there is a named person at Question 8)?
Give reasons
D) Do you want to prohibit the respondent from contacting the aggrieved or asking someone else to contact the aggrieved? No Yes
Does this include any associates or relatives (if there is a named person at Question 8)? No Yes
Give reasons
E) Do you want to prohibit the respondent’s presence at or in a place associated with any child (e.g. school, day care etc.) No Yes
Give reasons
F) If the respondent does not know the aggrieved’s whereabouts, do you want to prohibit the respondent from trying to locate them or asking
someone else to locate them? No Yes
Give reasons
G) Does the aggrieved wish to recover essential property? No Yes
Describe the property and state address where this property can be located.
H) Do you want the court to consider prohibiting any other conduct or behaviour on the part of the respondent? No Yes
Specify that conduct or behaviour complain of and give reasons
Domestic and Family Violence Protection Act 2012
Form DV1 – version 3 – 25 November 2017
Page 8 of 8
12. Statutory Declaration
The applicant, except if a member of the Queensland Police Service, must sign this application in the presence of a Justice of the Peace,
Commissioner for Declarations, or a Solicitor
I, the applicant in this application, do solemnly and sincerely declare:
The information set out in this application, and any other attached statement, is true and correct to the best of my knowledge and belief. I
make this solemn declaration conscientiously believing the same to be true and by virtue of the provisions of the Oaths Act 1867.
Declared by on / / at in the
presence of
(Signature of Applicant)
…………………………………………….
(Signature of person taking statement)
………………………………………………..
(Full name of Applicant))
…………………………………………….
(Full name and Qualification of Witness)
……………………………………………….
……………………………………………….
Queensland Police Service Applicant
The applicant, if a member of the Queensland Police Service, must sign this application and provide the details below:
Full Name and Rank:
Registration No:
Signature:
Date:
Notes to the respondent
If you do not appear in court a domestic violence order may be made in your absence.
The court may issue a warrant for you to be taken into custody by a police officer and brought before the court if the court believes that it
is necessary for you to be heard.
Office Use Only
Court file number (if known) :
YOU ARE NOTIFIED that this application will be heard at the time and place as follows:
Court:
Place:
Date:
Time:
Signature
Clerk of the Court/Queensland Police Service
Domestic and Family Violence Protection Act 2012
Form DV1 – version 3 – 25 November 2017
Queensland
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FORM DV1: Application for a Protection Order (Department of the Environment and Energy)

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Completed 28 March 2022

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