Fillable Form 1: DV-100 Violence Restraining Order Request for (San Mateo County Law Library)

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Form 1: DV-100 Violence Restraining Order Request for (San Mateo County Law Library)

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The Form 1: DV-100 Violence Restraining Order Request for (San Mateo County Law Library) form is 5 pages long and contains:

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  • 50 check-boxes
  • 150 other fields

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File type: PDF

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We are now married or registered domestic partners.
a.
b
.
This is not a Court Order.
Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
Clerk stamps date here when form is filed.
Fill in court name and street address:
Superior Court of California, County of
Case Number:
Clerk fills in case number when form is filed.
DV-100
Request for Domestic
Violence Restraining Order
4
What is your relationship to the person in ? (Check all that apply):
We used to be married or registered domestic partners.
c.
We live together.
d.
We used to live together.
3
2
Name of person asking for protection:
Your lawyer in this case (if you have one):
Telephone:
1
2
You must also complete Form CLETS-001, Confidential CLETS Information
and give it to the clerk when you file this Request.
Age:
Name:
State Bar No.:
Address:
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.):
Fax:
Firm Name:
E-Mail Address:
Name of person you want protection from:
Zip:
State:
City:
Full name
M F Height: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:
Yes
No
Sex
Age
Lives with you?
Yes
No
Relationship to you
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.
3
If yes, list them:
If you do not have one of these relationships,
the court may not be able to consider your
request. Read DV-500-INFO for help.
Child’s Name: Date of Birth:
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:
Child’s Name: Date of Birth:
Child’s Name: Date of Birth:
Check here if you need more space. Attach a sheet of paper and write “DV-100, Children Under 18” for a
h.
We have signed a Voluntary Declaration of Paternity for our child or children. (Attach a copy if you have one).
title.
Judicial Council of California, www.courts.ca.gov
Revised January 2, 2012, Mandatory Form
Family Code, § 6200 et seq.
DV-100, Page 1 of 5
To keep other people from
seeing what you entered on
your form, please press the
Clear This Form button at the
end of the form when finished.
Are there any domestic violence restraining/protective orders now (criminal, juvenile, family)?
b
.
No
Yes
If yes, attach a copy if you have one.
Check the orders you want.
6
Personal Conduct Orders
Harass, attack, strike, threaten, assault (sexually or otherwise), hit, follow, stalk, molest, destroy personal
a.
property, disturb the peace, keep under surveillance, or block movements
7
Stay-Away Order
I ask the court to order the person in to stay at least yards away from (check all that apply):
a.
2
If the person listed in is ordered to stay away from all the places listed above, will he or she still be able
b
.
2
to get to his or her home, school, job, workplace, school, or vehicle?
Yes
No
(If no, explain):
This is not a Court Order.
8
Move-Out Order
I ask the court to order the person in to move out from and not return to (address):
2
I have the right to live at the above address because (explain):
Case Number:
Revised January 2, 2012
Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
(If the person in lives with you and you want that person to stay away from your home, you must ask for
2
this move-out order)
Me
My home
My job or workplace
My school
My vehicle
The children’s school or child care
Each person listed in
Other (specify):
3
I ask the court to order the person in not to do the following things to me or anyone listed in :
2
3
5
Other Court Cases
Have you or any other person named in item been involved in another court case with the person in ?
a.
3
2
No
Yes
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)
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.
DV-100, Page 2 of 5
Contact, either directly or indirectly, in any way, including but not limited to, by telephone, mail or
e-mail or other electronic means
b
.
The person in will be ordered not to take any action to get the addresses or locations of any protected
2
person unless the court finds good cause not to make the order.
Guns or Other Firearms and Ammunition
This is not a Court Order.
Property Restraint
2
I believe the person in owns or possesses guns, firearms, or ammunition.
2
Yes
No
I don’t know
guns or firearms that he or she owns or possesses.
Record Unlawful Communications
I ask for the right to record communications made to me by the person in that violate the judge’s orders.
2
Animals: Possession and Stay-Away Order
I ask for the sole possession, care, and control of the animals listed below. I ask the court to order the person in
2
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:
Property Control
I ask the court to give only me temporary use, possession, and control of the property listed here:
Debt Payment
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:
Case Number:
Revised January 2, 2012
Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
9
12
16
10
11
13
14
15
Check here if you need more space. Attach a sheet of paper and write “DV-100, Debt Payment” for a title.
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.
2
2
2
DV-100, Page 3 of 5
Child Custody and Visitation
I do not have a child custody or visitation order and I want one.
a.
I have a child custody or visitation order and I want it changed.
b
.
If you ask for orders, you must fill out and attach Form DV-105, Request for Child Custody and Visitation
Orders.
Child Support (Check all that apply):
I do not have a child support order and I want one.
a.
I have a child support order and I want it changed.
b
.
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).
I now receive or have applied for TANF, Welfare, CalWORKS, or Medi-Cal.
c.
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 a gun dealer or turn in to law enforcement any
2
This is not a Court Order.
Other Orders
2
What other orders are you asking for?
Spousal Support
2
Payments for Costs and Services
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: $
Batterer Intervention Program
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.
2
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.
Court Hearing
Case Number:
Revised January 2, 2012
Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
21
17
18
19
20
22
23
24
Check here if you need more space. Attach a sheet of paper and write “DV-100, Other Orders” for a title.
Time for Service (Notice)
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?”
3
3
3
2
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.
DV-100, Page 4 of 5
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 fill out, file, and serve Form
FL-150, Income and Expense Declaration, before your hearing).
Lawyer’s Fees and Costs
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.
2
2
2
This is not a Court Order.
Date:
Type or print your name
Sign your name
Case Number:
Revised January 2, 2012
Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
26
Other Persons to Be Protected
The persons listed in item need an order for protection because (describe):
2
2
Check here if you need more space. Attach a sheet of paper and write “DV-100, Recent Abuse” for a title.
27
25
Describe Abuse
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
molest, attack, hit, stalk, threaten, batter, harass, telephone, or contact you; or to disturb your peace; or to destroy
your personal property. Abuse can be spoken, written, or physical. (For a complete definition, see Family Code
§§ 6203, 6320).
2
Date of most recent abuse:
a.
Who was there?
b
.
Describe how the person in abused you or your children:
c.
2
Did the person in use or threaten to use a gun or any other weapon?
d.
No
Yes
(If yes, describe):
Describe any injuries:
e.
Did the police come?
f.
No
Yes
If yes, did they give you or the person in an Emergency Protective Order?
2
Yes
No
I don’t know
Attach a copy if you have one.
The order protects
you or the person in
3
Has the person in abused you (or your children) other times?
g.
2
If yes, check here and use Form DV-101, Description of Abuse or a sheet of paper to describe any
previous abuse.
Number of pages attached to this form, if any:
I declare under penalty of perjury under the laws of the State of California that the information above is true and correct.
Lawyer’s signature
Date:
Lawyer’s name, if you have one
DV-100, Page 5 of 5
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button after you have printed the form.
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Form 1: DV-100 Violence Restraining Order Request for (San Mateo County Law Library)

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Completed 15 December 2020

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