Fillable Form 1: DV-100 Request for Domestic Violence Restraining (California)

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Form 1: DV-100 Request for Domestic Violence Restraining (California)

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The Form 1: DV-100 Request for Domestic Violence Restraining (California) form is 6 pages long and contains:

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  • 66 check-boxes
  • 160 other fields

Country of origin: US
File type: PDF

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Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
Request for Domestic
Violence Restraining Order
What is your relationship to the person in ?
(Check all that apply):
You must also complete Form CLETS-001, Confidential CLETS Information,
and give it to the clerk when you file this Request.
Age:
Name of Person You Want Protection From:
Full name
Sex:
Address (if known):
Race: Date of Birth:
City:
Age:
Do you want an order to protect family or household members?
Description of person you want protection from:
Weight: Hair Color: Eye Color:
State: Zip:
Sex
Age
Lives with you?
Relationship to you
If yes, list them:
If you do not have one of these relationships,
the court may not be able to consider your
request. Read Form DV-500-INFO for help.
Child’s Name:
Date of Birth:
Child’s Name:
Date of Birth:
Child’s Name:
Date of Birth:
Judicial Council of California, www.courts.ca.gov
Revised July 1, 2016, Mandatory Form
Family Code, § 6200 et seq.
DV-100, Page 1 of 6
DV-100
Name of Person Asking for Protection:
Address (If you have a lawyer for this case, give your lawyer’s
information. If you do not have a lawyer and want to keep your home
address private, give a different mailing address instead. You do not have
to give your telephone, fax, or e-mail.):
Firm Name:
Your lawyer in this case (if you have one):
Name:
State Bar No.:
Telephone:
Address:
Fax:
E-Mail Address:
Zip:State:City:
M F Height:
Yes
No
Yes
No
Yes
No
Yes
No
Check here if you need more space. Attach a sheet of paper and write “DV-100, Protected People” for a title.
a.
b.
We are now married or registered domestic partners.
We used to be married or registered domestic partners.
c.
We live together.
d.
We used to live together.
e.
We are related by blood, marriage, or adoption (specify relationship):
f.
We are dating or used to date, or we are or used to be engaged to be married.
g.
We are the parents together of a child or children under 18:
Check here if you need more space. Attach a sheet of paper and write “DV-100, Additional Children” for a
title.
h.
We have signed a Voluntary Declaration of Paternity for our child or children. (Attach a copy if you have
one).
This is not a Court Order.
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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:
Check the orders you want.
I ask the court to order the person in to stay at least yards away from (check all that apply):
Me
My home
My job or workplace
My school
My vehicle
The child(ren)’s school or child care
Each person listed in
Other (specify):
a.
b.
Revised July 1, 2016
(If the person in lives with you and you want that person to stay away from your home, you must ask for
this move-out order.)
I ask the court to order the person in not to do the following things to me or anyone listed in :
Other Restraining Orders and Court Cases
Have you or any other person named in been involved in another court case with the person in ?
If yes, check each kind of case and indicate where and when each was filed:
Kind of Case County or Tribe Where Filed Year Filed
Case Number (if known)
DV-100, Page 2 of 6
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.
If the person listed in is ordered to stay away from all the places listed above, will he or she still be able to
get to his or her home, school, job, workplace, or vehicle?
Case Number:
b.
No
Yes
Divorce, Nullity, Legal Separation
Civil Harassment
Domestic Violence
Criminal
Juvenile, Dependency, Guardianship
Child Support
Parentage, Paternity
Other (specify):
Check here if you need more space. Attach a sheet of paper and write “DV-100, Other Court Cases” for a
title.
Move-Out Order
I ask the court to order the person in to move out from and not return to (address):
I have the right to live at the above address because (explain):
This is not a Court Order.
Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
Harass, attack, strike, threaten, assault (sexually or otherwise), hit, follow, stalk, molest, destroy personal
property, disturb the peace, keep under surveillance, impersonate (on the Internet, electronically or
otherwise), or block movements
Personal Conduct Orders
þ
a.
b.
Contact, either directly or indirectly, in any way, including but not limited to, by telephone, mail or e-mail
or other electronic means
Stay-Away Order
Yes
No (If no, explain):
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Are there any restraining/protective orders currently in place OR that have expired in the last six months
(emergency protective orders, criminal, juvenile, family)?
a.
Yes
No
(date of order): and (expiration date): (Attach a copy if you have one).
I believe the person in owns or possesses guns, firearms, or ammunition.
I ask for the right to record communications made to me by the person in that violate the judge’s orders.
Revised July 1, 2016
DV-100, Page 3 of 6
If you ask for orders, you must fill out and attach Form DV-105, Request for Child Custody and Visitation Orders.
If you ask for child support orders, you must fill out and attach form FL-150
, Income and Expense Declaration or
Form FL-155, Financial Statement (Simplified).
You and the other parent may tell the court that you want to be legal parents of the children (use Form DV-180
,
Agreement and Judgment of Parentage).
If the judge approves the order, the person in will be ordered not to own, possess, purchase, or receive a
firearm or ammunition. The person will be ordered to sell to, or store with, a licensed gun dealer, or turn in to law
enforcement, any guns or firearms that he or she owns or possesses.
Case Number:
Guns or Other Firearms or Ammunition
Yes
No
I don’t know
Record Unlawful Communications
Care of Animals
I ask for the sole possession, care, and control of the animals listed below. I ask the court to order the person in
to stay at least yards away from and not take, sell, transfer, encumber, conceal, molest, attack,
strike, threaten, harm, or otherwise dispose of the following animals:
I ask for the animals to be with me because:
Child Custody and Visitation
a.
b.
I do not have a child custody or visitation order and I want one.
I have a child custody or visitation order and I want it changed.
Child Support (Check all that apply):
a.
b.
I do not have a child support order and I want one.
I have a child support order and I want it changed.
c.
I now receive or have applied for TANF, Welfare, CalWORKS, or Medi-Cal.
Property Control
I ask the court to give only me temporary use, possession, and control of the property listed here:
This is not a Court Order.
Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
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Debt Payment
Check here if you need more space. Attach a sheet of paper and write “DV-100, Debt Payment” for a title.
I ask the court to order the person in to make these payments while the order is in effect:
Pay to: For: Amount: $ Due date:
2
Property Restraint
I am married to or have a registered domestic partnership with the person in . I ask the judge to order
that the person in not borrow against, sell, hide, or get rid of or destroy any possessions or property, except
in the usual course of business or for necessities of life. I also ask the judge to order the person in to notify
me of any new or big expenses and to explain them to the court.
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2
2
I am married to or have a registered domestic partnership with the person in and no spousal support order
exists. I ask the court to order the person in to pay spousal support. (You must complete, file, and serve Form
FL-150, Income and Expense Declaration, before your hearing).
Spousal Support
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2
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What other orders are you asking for?
I ask the court to order the person in to pay the following:
You can ask for lost earnings or your costs for services caused directly by the person in (damaged property,
medical care, counseling, temporary housing, etc.). You must bring proof of these expenses to your hearing.
Pay to: For: Amount: $
Pay to: For: Amount: $
I ask the court to order the person listed in to go to a 52-week batterer intervention program and show proof
of completion to the court.
Revised July 1, 2016
DV-100, Page 4 of 6
I ask that the person in pay some or all of my lawyer’s fees and costs.
You must complete, file, and serve form FL-150, Income and Expense Declaration, before your hearing.
Case Number:
Insurance
I ask the court to order the person in NOT to cash, borrow against, cancel, transfer, dispose of, or change the
beneficiaries of any insurance or coverage held for the benefit of me or the person in , or our child(ren), for
whom support may be ordered, or both.
Lawyer’s Fees and Costs
Payments for Costs and Services
Batterer Intervention Program
Other Orders
Check here if you need more space. Attach a sheet of paper and write “DV-100, Other Orders” for a title.
Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
This is not a Court Order.
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Rights to Mobile Device and Wireless Phone Account
(including area code):
(including area code):
(including area code):
my number number of child in my care
my number number of child in my care
my number number of child in my care
Check here if you need more space. Attach a sheet of paper and write “DV-100, Rights to Mobile Device
and Wireless Phone Account” for a title.
If the judge makes this order, you will be financially responsible for these accounts, including monthly service
fees and costs of any mobile devices connected to these phone numbers. You may be responsible for other fees.
You must contact the wireless service provider to find out what fees you will be responsible for and whether you
are eligible for an account.
I ask the court to give only me temporary use, possession, and control of the following mobile devices:
and the wireless phone account for the
following wireless phone numbers because the account currently belongs to the person in :
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18
a.
Property control of mobile device and wireless phone account
b.
Debt Payment
I ask the court to order the person in to make the payments for the wireless phone accounts listed in 18a
because:
2
Name of the wireless service provider is: Amount: $ Due Date:
If you are requesting this order, you must complete, file, and serve Form FL-150, Income and Expense
Declaration, before your hearing.
c.
Transfer of Wireless Phone Account
I ask the court to order the wireless service provider to transfer the billing responsibility and rights to the
wireless phone numbers listed in 18a to me because the account currently belongs to the person in .
2
Describe how the person in abused you or your child(ren):
Revised July 1, 2016
Describe how the person in abused you. Abuse means to intentionally or recklessly cause or attempt to cause
bodily injury to you; or to place you or another person in reasonable fear of imminent serious bodily injury; or to
harass, attack, strike, threaten, assault (sexually or otherwise), hit, follow, stalk, molest, keep you under
surveillance, impersonate (on the Internet, electronically or otherwise), batter, telephone, or contact you; or to
disturb your peace; or to destroy your personal property. (For a complete definition, see Fam. Code, §§ 6203, 6320.)
Date of most recent abuse:
Who was there?
Did the person in use or threaten to use a gun or any other weapon?
2
Describe any injuries:
Did the police come?
If yes, did they give you or the person in an Emergency Protective Order?
Attach a copy if you have one.
The order protects
DV-100, Page 5 of 6
Case Number:
Describe Abuse
a.
1.
2.
Check here if you need more space. Attach a sheet of paper and write “DV-100, Recent Abuse” for a title.
3.
4.
5.
No
Yes (If yes, describe):
No
Yes
you or the person in
This is not a Court Order.
I don’t knowYes No
No Fee to Serve (Notify) Restrained Person
If you want the sheriff or marshal to serve (notify) the restrained person about the orders for free, ask the court
clerk what you need to do.
The court will schedule a hearing on your request. If the judge does not make the orders effective right away
(“temporary restraining orders”), the judge may still make the orders after the hearing. If the judge does not make
the orders effective right away, you can ask the court to cancel the hearing. Read form DV-112, Waiver of Hearing
on Denied Request for Temporary Restraining Order, for more information.
Court Hearing
The papers must be personally served on the person in at least five days before the hearing, unless the
court orders a shorter time for service. If you want there to be fewer than five days between service and the
hearing, explain why below. For help, read Form DV-200-INFO, “What Is Proof of Personal Service”?
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Time for Service (Notice)
Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
I don’t know
Yes No
Revised July 1, 2016
The persons listed in item need an order for protection because (describe):
I declare under penalty of perjury under the laws of the State of California that the information above is true and correct.
DV-100, Page 6 of 6
Case Number:
Other Persons to Be Protected
Number of pages attached to this form, if any:
Date:
Type or print your name
Sign your name
Lawyer’s name, if you have one
Lawyer’s signature
Date:
This is not a Court Order.
Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
Has the person in abused you (or your child(ren)) other times?
Describe Abuse (continued)
Date of abuse:
Who was there?
Did the person in use or threaten to use a gun or any other weapon?
Describe any injuries:
Did the police come?
If yes, did they give you or the person in an Emergency Protective Order?
Attach a copy if you have one.
The order protects
b.
1.
2.
Describe how the person in abused you or your child(ren):
Check here if you need more space. Attach a sheet of paper and write “DV-100, Recent Abuse” for a
title.
3.
4.
5.
No Yes (If yes, describe):
No Yes
you or the person in
If the person in abused you other times, check here and use Form DV-101, Description of Abuse
or describe any previous abuse on an attached sheet of paper and write “DV-100, Previous Abuse” for a
title.
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Form 1: DV-100 Request for Domestic Violence Restraining (California)

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Completed 20 November 2020

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