Fillable FORM DV4: Application to vary a domestic violence (Department of the Environment and Energy)

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FORM DV4: Application to vary a domestic violence (Department of the Environment and Energy)

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The FORM DV4: Application to vary a domestic violence (Department of the Environment and Energy) form is 4 pages long and contains:

  • 2 signatures
  • 28 check-boxes
  • 106 other fields

Country of origin: AUSTRALIA
File type: PDF

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Domestic and Family Violence Protection Act 2012
Form DV4 – version 6 – 21 September 2021 Page 1 of 4
FORM DV4
Domestic and Family Violence Protection Act 2012 s.86
Application to vary a domestic violence 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 Family Name Date of Birth Gender
Address *leave blank if you do not want this information to be given to the other party
SPI# (QPS Only) Phone Number Email address
Do you require an interpreter? No Yes Language/Dialect:
Do you identify as: Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander Neither
Do you 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 the parent of the aggrieved unless the court orders otherwise.
Parents Name
Parents Address
2. Respondent’s Details
Given Name Family Name Date of Birth Gender
Address
SPI# (QPS Only) Phone Number Email address
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
Do you 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 the parent of the aggrieved unless the court orders otherwise.
Parents Name
Parents Address
Domestic and Family Violence Protection Act 2012
Form DV4 – version 6 – 21 September 2021 Page 2 of 4
3. Applicant’s Details
Part A - Any other applicant who is not the Aggrieved or a member of the Queensland Police Service
Given Name Family Name Date of Birth Gender
Address *leave blank if you do not want this information to be given to the other party
Phone Number Email address
Do you require an interpreter? No Yes Language/Dialect:
Do you identify as: Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander Neither
Do you have a disability, illness or impairment where support and/or special arrangements are required? No Yes
What type of applicant are you?
Respondent in the existing order
A person being authorised by the aggrieved (please provide proof of authorisation)
A person acting under another Act for the aggrieved, respondent or a named person
A named person in the existing order
Part B – A Police Officer
Full Name including Rank: Registration #
Station Police Occurrence #
Has the aggrieved been advised of this application? No Yes
Proceed to Question 4
4. Existing Order Details
Please provide a copy of the original order with this application. If you are unable to do so, court registry staff will obtain a copy on your behalf
Is the existing order:
A temporary protection order A protection order
Date the original order or declared The court and location the original order was made or declared
Any domestic violence order made by a court or police officer in Australia from 25 November 2017 is automatically a nationally recognised
domestic violence order.
A) Was the existing order made before 25/11/2017 No Yes
If want the DVO to be nationally recognised, you will be required to make an application to declare the DVO to be a nationally recognised
order.
B) Do you want to apply to declare the order to be a recognised interstate order? No Yes
Proceed to Question 5
5. Details of Variation
A) Do you want to vary the conditions of the order? No Yes
Please provide details of the condition/s that you would like added or varied.
Domestic and Family Violence Protection Act 2012
Form DV4 – version 6 – 21 September 2021 Page 3 of 4
Give reasons
B) Do you want to vary the duration of the order? No Yes
When would you like the order to end?
Give reasons
C) Do you want to vary the persons named in the order? No Yes
Provide details of the persons named in the order that you would like removed or added
Full Name
Gender
Date of Birth
Address
Give reasons
Proceed to Question 6
6. 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 7
7. Details of any other Orders
Has the court made any other order or are there other court proceedings that involve the aggrieved and the respondent? Please provide a copy
of the original order with this application. If you are unable to do so, court registry staff will obtain a copy on your behalf
Childrens Court Orders Yes No
Police Protection Notice Yes No
Intervention Order Yes No
Interstate Domestic Violence Orders (including New Zealand) Yes No
Family Court Orders Yes No
Other relevant court order Yes No
Domestic and Family Violence Protection Act 2012
Form DV4 – version 6 – 21 September 2021 Page 4 of 4
8. 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 QUEENSLAND 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 (who is also the respondent named in an existing order)
If you do not appear in court, the court may hear and decide the application 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
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FORM DV4: Application to vary a domestic violence (Department of the Environment and Energy)

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Completed 16 January 2022

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