Fillable Instructions for Petition for Order for Protection (Kittitas County WA)

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Instructions for Petition for Order for Protection (Kittitas County WA)

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DVI-1.015 (07/2019) Page 1 of 7 Petition
Instructions for Petition for Order for Protection
This form is used to start a domestic violence protection order case. Ask the court clerk for advocate
services to help you fill out this form. This form will be:
• Filed as a public court record and will start a civil court case.
• Served (personal delivery) to the person from whom you need protection.
The information in the petition is used by the court to determine if:
• The court has authority to enter an order on your behalf.
• If the relationship between you and the other party meets the legal definition of family or
household member.
• If the respondent’s behavior towards you meets the legal definition of domestic violence.
Use this petition to request both immediate temporary protection and full protection.
Immediate Protection: If you need immediate protection, and the court finds an emergency exists, the court
may immediately issue a temporary order that will last until the court holds a hearing, usually within 14 days.
During the 14 days, the respondent must be served the:
• petition,
• temporary order and notice of hearing,
• any order to surrender weapons issued without notice, and
• any other declarations or documents, if any, presented to the court.
If the court orders respondent to surrender weapons, the local law enforcement agency must serve the
order.
In cases without an order to surrender weapons, service may be done by:
• a law enforcement agency where the respondent lives or works, free of charge,
• a hired professional process server, or
• a person 18 or over who is not a party to this action.
The person completing service on the respondent must file an affidavit, declaration, or certificate of
service with the court or the hearing cannot go forward.
Full Order for Protection: At the hearing, the court will determine if it should issue a full Order for
Protection. The respondent has a right to attend that hearing.
Print Clearly! Use Black or Blue Ink only.
Top of the form (Page 1)
Fill in your name (first, middle initial, last) as the “Petitioner.” The person you want protection from is the
“Respondent.” Fill in the respondent's name (first, middle initial, last).
Who Needs Protection (Question 1)
The court must know who needs protection. Check the first box if you need protection. Check the
second box if someone in your family or household needs protection. You may check both boxes. Check the
third box if you are the guardian, guardian ad litem or next friend of a minor 13 – 15 years of age who is a
DVI-1.015 (07/2019) Page 2 of 7 Petition
victim of domestic violence in a dating relationship with a person 16 years of age or older, who needs
protection. Include the minor’s name in the space provided within the third check box and provide additional
identifying information for the minor in paragraph 5.
A next friend is a competent person, over 18 years of age, chosen by the minor who is capable of
pursuing the minor’s stated interest in the petition for order for protection action.
Residency (Question 2)
Check the box that applies.
Age (Question 3)
The court needs to know the ages of the petitioner/victim and the respondent. Check one of the boxes
for the petitioner’s/victim’s age. Check one of the boxes for the respondent's age.
Relationship (Question 4)
The court must know the relationship between the petitioner/victim and the respondent. The court needs
to know if the petitioner/victim and the respondent are “intimate partners” or “family or household members.”
Check the box that best describes your situation. If you are petitioning on behalf of a minor, the minor’s
relationship to the respondent is addressed in question 5.
Identification of Minors (Question 5)
• If there are no children, check the box indicating “No Minors Involved.”
• If there are children, list each child's name, age, race and sex. Fill in how that child is related to you
(for example, son, stepdaughter). Fill in how that child is related to the respondent. Fill in with whom
that child lives (for example: me, grandparent, respondent).
• If you have questions about safety for your children, ask for advocate resources for help in filling out
this section.
Court Cases (Question 6)
This may not be the first court proceeding involving you, or the minors, and the respondent. The court will
need to know about other cases, such as divorce, parentage or criminal, or other restraining, protection or no-
contact orders so the court does not issue an order that might conflict with an order from another court.
If there are other cases or orders involving you, or the minors, and the respondent, list the case title (the
parties' names), the case number (if you know it), and the court (district, municipal, or superior) and the
county in the columns provided.
Request for Protection (Page 2)
In this section, you must tell the court what you want the court to order after the hearing (the relief
requested). The court can only grant the relief you request in the petition.
Some provisions allow you to ask the court to protect you, all the minors listed in paragraph 5 or only
minors you name. Some provisions allow you to specify which locations you want included in the protection.
Be sure to check the boxes to specify which people and places you want protected within each restraint
provision.
DVI-1.015 (07/2019) Page 3 of 7 Petition
1. The first provision asks the court to restrain the respondent from causing physical harm, bodily injury,
assault, including sexual assault, and from molesting, harassing, threatening or stalking you and/or the
children you name.
2. The second provision asks the court to restrain the respondent from harassing, following, keeping under
surveillance, including cyberstalking, or from using telephonic, audiovisual or other electronic means to
monitor the actions, locations or communications of you and/or the minors listed in paragraph 5, only the
minors you name in this provision. You may also ask for protection in this provision for the victim’s adult
children and/or any of the victim’s household members. Write in the names of the adult children or
household members in the space provided.
3. The third provision asks the court to restrain the respondent from contacting you and/or the children you
name.
4. The fourth provision asks the court to exclude the respondent from your home, workplace, school or the
minor’s day care or school. If there is someplace else you want to include, add it to the box called “other.”
You have a right to keep your residential address confidential (secret). This restraint provision in the
temporary order and in the full order has a space for you to write in your residential address. You are not
required to write in your residential address if you are concerned with your safety or with identity theft.
However, enforcement of the order may be easier if your address is included. If you decide to include
your address, please list the complete address, including the city.
5. The fifth provision asks the court to order the respondent to vacate the home the two of you share and to
give you exclusive rights to the home.
6. The sixth provision asks the court to prohibit the respondent from knowingly coming within or knowingly
remaining within a specified distance (e.g. 100 feet, 2 blocks) of your home, workplace or school; or the
minor’s day care or school. If there is someplace else you want to include, add it to the box called “other.”
7. The seventh provision asks the court to grant you possession of essential personal belongings. Please
list the personal belongings. (“Essential personal belongings” means those items necessary for a person's
immediate health, welfare, and livelihood. “Essential personal belongings” includes but is not limited to
clothing, cribs, bedding, documents, medications, and personal hygiene items. (RCW 26.50.010(7))
8. The eighth provision asks the court to grant you use of a vehicle (i.e., blue 1994 Ford Taurus, License
Number XYZ123).
9. The ninth provision, “Other,” is where you may list something not mentioned in the above provisions.
If There Are No Minors Involved Do Not Check Provisions 10, 11, and 12.
If You Are Requesting Restraint Provisions Involving Minors Check the Boxes in 10, 11, and 12.
10. The tenth provision asks the court to grant (give) you the temporary care, custody and control of the
children you name, subject to any visitation with the respondent the court may order.
11. The eleventh provision asks the court to restrain the respondent from interfering with your custody of the
children you name.
12. The twelfth provision asks the court to restrain the respondent from removing the listed children from the
state.
Additional Requests
DVI-1.015 (07/2019) Page 4 of 7 Petition
13. The thirteenth provision asks the court to direct the respondent to get treatment or counseling.
14. The fourteenth provision asks the court to require the respondent to pay the fees and costs of this action.
(Fees and costs may include court costs, service fees and reasonable attorney's fees or reasonable fees
for a limited license legal technician (LLLT) (APR 28).)
15. The fifteenth provision asks the court to make the order remain effective (last longer) than one year.
Check this box only if there is reason to believe the respondent would resume the acts of domestic
violence against you if the order expired in one year.
Protection involving pets
16. The sixteenth provision asks the court to grant you exclusive custody and control of pet(s). You can only
ask for custody and control of a pet if it is owned, possessed, leased, kept, or held by you, the
respondent, or a minor child residing with either you or the respondent.
17. The seventeenth provision asks the court to prohibit the respondent from interfering with your efforts to
remove the pet(s).
18. The eighteenth provision asks the court to prohibit the respondent from knowingly coming within or
knowingly remaining within a specified distance (e.g. 100 feet, 2 blocks) from the location(s) you list
where the pet(s) may regularly be found. Remember, you have a right to keep your residential address
confidential.
Protection from Firearms and Other Dangerous Weapons
19. The nineteenth provision asks the court to require the respondent to immediately surrender all firearms,
other dangerous weapons, and any concealed pistol licenses, and to prohibit the respondent from
accessing, obtaining or possessing a firearm or other dangerous weapon, or concealed pistol licenses
until the order ends.
Notice: If you are the respondent’s intimate partner, after actual notice and an opportunity to be heard
at the hearing, the court may be required by law to order the respondent to immediately surrender all
firearms, other dangerous weapons, or concealed pistol licenses.
Please review the section you just completed to ensure that you checked the boxes to show which
provisions you want the court to order. In each provision, be sure you checked the boxes to identify the
people and places you want protected.
Emergency temporary protection effective immediately, without notice to the respondent, that lasts (up
to 14 days) until the court hearing.
Check the box if an emergency exists and you want to ask the court to issue a temporary order
immediately.
Check the box if you want to ask the court to order the respondent to surrender all firearms or other
dangerous weapons, and any concealed pistol licenses immediately.
In the space below the check boxes, explain what irreparable harm (harm beyond repair) would result if
the court did not issue temporary protection.
Request for Special Assistance from Law Enforcement Agencies
DVI-1.015 (07/2019) Page 5 of 7 Petition
You might need special help from the police. Check off everything that you think you may need the police
to assist you in obtaining.
1. The first item asks the court to order the police to help you get back into your home. For your safety, ask
for a police escort back into your home.
2. The second item asks the court to order the police to help you get use of the vehicle.
3. The third item asks the court to order the police to help you get your personal belongings (Civil Standby).
Check the box if you want the police to help you get your belongings from the shared residence, the
respondent’s residence or another location. Because of time limitations, availability of officers and safety,
contact law enforcement to schedule a civil standby (when they will meet you and how long they can
stay).
4. The fourth item asks the court to order the police to help you get custody of the children you list. There
may be additional steps that you have to take for this request to be enforced.
5. The last item lets you ask for other help you might need from the police.
Statement of Petitioner
The statement of petitioner is to describe to the court why a protection order is needed. This document will
be filed in the court file, which is a public record, and shall be served on the respondent. If you do not include
a particular incident of domestic violence in your statement, you may not have an opportunity to tell the court
at the hearing.
“Domestic violence” means physical harm, bodily injury, assault, including sexual assault, stalking, Or
inflicting fear of imminent physical harm, bodily injury or assault between family or household
members.
First read through the statement section in the petition before you start writing. There are several places
for you to describe what happened.
Describe exactly what happened when you were threatened or hurt. Provide as much detail as you can
such as dates, times, witnesses, injuries, if any, medical treatment, if any. The more details you can provide
the more helpful it is to the judge. If there is an emergency, explain why so the court can issue an immediate
temporary order before the hearing. In addition to the information requested in the statement you may want
to include:
• If the respondent has hurt other people.
• If the respondent has been arrested.
• If police responded even if no arrests were made.
Examples:
It is better to say “On Sunday, January 12, at 2:00 a.m., Terry slapped my face.” Rather than
“On Sunday Terry assaulted me.”
It is better to say “Terry threatened to kill me if I left the house. He said ‘You leave and I will kill
you.’” Rather than “Terry threatened me.”
It is better to say “Terry drives by me while I’m waiting at the bus stop after work every Monday
evening.” Rather than “Terry is stalking me.”
DVI-1.015 (07/2019) Page 6 of 7 Petition
It is better to say “Terry sends me emails or text messages [include number] times a day. I
texted Terry to stop; but Terry keeps sending the messages.” Rather than “Terry cyber stalks
me.”
Try to use the respondent’s exact words when you were threatened with physical harm.
If any of the information requested does not apply, write, “does not apply” in that section.
Choose the appropriate box if substance abuse is involved.
Out of State Service
If the respondent cannot be personally served in Washington State, check the box. Note: The
respondent will still have to be personally served, unless the court orders otherwise.
Sign the Form
When you are done with your statement, put today’s date in the date line and fill in the city where you are
completing this form. Sign the form.
The respondent has a right to have you served with documents in response to this petition. You have a
right to keep your residential address confidential. If you want to keep your address confidential, you must
list an address that is not your residential address where you agree to accept legal documents.
Complete the Temporary Orders
If you ask the court for immediate protection, complete the Temporary Order for Protection and Notice of
Hearing, form DV 2.015. Follow the instructions for that form.
If you ask the court to order the respondent to surrender firearms and other dangerous weapons, bring
the Order to Surrender Weapons Issued Without Notice form, All Cases 02-030, for the judge to complete.
Go to Court
Bring your completed petition and temporary order and the blank order to surrender weapons to the
clerk’s office of the local court. They will direct you further.
Service of Court documents
Unless the respondent or the respondent’s lawyer was present at the hearing, the petition, any temporary
order, and any order to surrender weapons must be served on the respondent. The respondent must know
what restraint provisions are in place, when and where the hearing will occur and when the order expires.
If you filed on behalf of a vulnerable adult, unless the vulnerable adult or the vulnerable adult’s lawyer
was present at the hearing, the petition and any temporary order and order to surrender weapons must be
served on the vulnerable adult. The vulnerable adult must know what restraint provisions are in place, when
and where the hearing will occur and when the temporary order expires. The vulnerable adult’s guardian, if
any must also be served.
If the court orders respondent to surrender weapons, the local law enforcement agency must serve the
order.
If the court does not order respondent to surrender weapons, you may choose service by:
DVI-1.015 (07/2019) Page 7 of 7 Petition
• A law enforcement agency, which will serve your papers free of charge.
• A hired professional process server.
• Another person 18 or over, who is not a party to this action.
• Mail or publication, if the judge previously entered an order allowing service by mail or publication.
You will need to provide the address for each person to be served. If you want law enforcement to serve
the documents, complete the Law Enforcement Information Sheet.
Law Enforcement Information Sheet (LEIS)
You must complete a Law Enfor
cement Information Sheet (LEIS), form WPF All Cases 01.0400. This
form is confidential and it does not go in the public court file and is not served on the respondent.
• It is used by Law Enforcement to locate and identify the respondent when serving documents.
• It is also used by Law Enforcement when entering the order in the state-wide data base.
Complete as much informat
ion as possible, especially, first name, middle initial, last name, and date of
birth.
If the respondent has a disability, brain injury, or other impairment, you may know of special assistance
that law enforcement could provide when serving the documents. For example:
“Respondent has a brain injury.
If respondent is rushed, respondent may freeze up and may not
respond quickly, or may become verbally aggressive. Remind respondent to contact a friend.”
“Respondent has epilepsy and diabet
es and may have seizures when stressed. Respondent doesn’t
respond well to being rushed and will need time to get meds and supplies.”
If you know the respondent has fi
rearms or other dangerous weapons, make sure you specify exactly
what types and numbers.
Traumatic Brain injury information:
Please be advised that law enforcement responding to any domestic violence incident is encouraged to
inform victims about a statewide website containing information about traumatic brain injuries.
https://www.doh.wa.gov/YouandYourFamily/InjuryandViolencePrevention/TraumaticBrainInjuries
and
https://www.dshs.wa.gov/altsa/traumatic-brain-injury/traumatic-brain-injury-advisory-council
Register for Auto
matic Notices about your Protection Order:
After the court issues
a temporary or full order for protection, you can register for automatic notices.
As authorized by RCW 36.28A
.410, WA VINE Protective Order is an automated service that allows you,
the petitioner, to track the status of a protective order over the phone or internet. You can also register to be
notified by phone and email about changes in the status of a protective order. If you register for notification,
you will receive important notifications regarding the service status of your protective order, a 90-day
expiration warning, and notification if the respondent in your order attempts to purchase/transfer a firearm
while they are prohibited and are denied.
To access protective order information, call 1-877-242-4055, or visit www.registervpo.com
. Do not rely
solely on WA VPO for your safety. If you feel you are in danger, call 9-1-1.
Petition for Order for Protection (PTORPRT) - Page 1 of 7
WPF DV-1.015 Mandatory (07/2019) - RCW 26.50.030
DISTRICT Court of Washington
For Lower Kittitas County
Petitioner
vs.
Respondent
No.
Petition for Order for Pr
otection
(PTORPRT)
1. [ ] I am a victim of domestic violence committed by the respondent.
[ ] A member of my family or household is a victim of domestic violence committed by the
respondent.
[ ] I am a [ ] guardian [ ] guardian ad litem [ ] next friend of a minor who is 13 to 15
years of age and is a victim of domestic violence in a dating relationship with a person
age 16 or older. The name of the minor victim is
_______________________________________. This person’s identifying information
is provided in paragraph 5 below.
2. [ ] The victim lives in this county.
[ ] The victim left their residence because of abuse and this is the county of their new or
former residence.
3. The victim’s age is: Respondent's age is:
[ ] Under 16 [ ] 16 or 17 [ ] 18 or over [ ] Under 16 [ ] 16 or 17 [ ] 18 or over
4. The victim and the respondent are:
[ ] Intimate Partners because they are:
[ ] current or former spouses or domestic partners [ ] parents of a child-in-common
[ ] age 16 or older and are/were in a dating relationship, and are currently residing
together or resided together in the past [ ] age 16 or older and are/were in a dating
relationship, but have never resided together.
[ ] Family or household members because they are:
[ ] current or former adult cohabitants as roommates [ ] adult in-laws [ ] adults
related by blood [ ] parent and child [ ] stepparent and stepchild [ ] grandparent
and grandchild.
Petition for Order for Protection (PTORPRT) - Page 2 of 7
WPF DV-1.015 Mandatory (07/2019) - RCW 26.50.030
5. Identification of Minors (if applicable) [ ] No Minors involved.
Name
(First, Middle Initial, Last)
Age
Race
Sex
How Related to
Petitioner Respondent
Resides
with
6. Other court cases or other restraining, protection or no-contact orders involving me, the
minors and the respondent:
Case Name
Case Number
Court/County
I Request an Order for Protection following a hearing that will:
1
[ ] Restrain respondent from causing any physical harm, bodily injury, assault, including
sexual assault, and from molesting, harassing, threatening, or stalking [ ] me [ ] the
minors named in paragraph 5 above [ ] these minors only:
(If the court orders this relief, and you and the respondent are current or former spouses or domestic
partners, parents of a child-in-common, age 16 or older and are/were in a dating relationship, and are
currently residing together or resided together in the past, age 16 or older and are/were in a dating
relationship, but have never resided together, the respondent will not be able to obtain or possess a
firearm, other dangerous weapon, ammunition, or concealed pistol license for the duration of the
order.)
2
[ ] Restrain respondent from harassing, following, keeping under physical or electronic
surveillance, cyberstalking as defined in RCW 9.61.260, and using telephonic,
audiovisual, or other electronic means to monitor the actions, locations, or wire or
electronic communication of [ ] me [ ] the minors named in paragraph 5 above [ ] only
the minors listed below; [ ] members of the victim’s household listed below [ ] the
victim’s adult children listed below:
3
[ ] Restrain respondent from coming near and from having any contact whatsoever, in
person or through others, by phone, mail, or any means, directly or indirectly, except for
mailing of court documents, with [ ] me [ ] the minors named in paragraph 5 above,
subject to any court-ordered visitation [ ] these minors only, subject to any court-
ordered visitation:
Petition for Order for Protection (PTORPRT) - Page 3 of 7
WPF DV-1.015 Mandatory (07/2019) - RCW 26.50.030
4
[ ] Exclude respondent from [ ] our shared residence [ ] my residence
[ ] my workplace [ ] my school [ ] the residence, day care, or school of [ ] the minors
named in paragraph 5 above [ ] these minors only:
[ ] other:
You have a right to keep your residential address confidential.
5
[ ] Direct respondent to vacate our shared residence and restore it to me.
6
[ ] Prohibit respondent from knowingly coming within, or knowingly remaining within
__________________ (distance) of [ ] our shared residence [ ] my residence [ ] my
workplace [ ] my school [ ] the day care or school of [ ] the minors named in
paragraph 5 above. [ ]
these minors only:
[ ] other:
7
[ ] Grant me possession of essential personal belongings, including the following:
8
[ ] Grant me use of the following vehicle:
Year, Make & Model _____________________________ License No.
9
[ ] Other:
Protection involving a minor:
10
[ ] Subject to any court-ordered visitation, Grant me the care, custody and control of
[ ] the minors named in paragraph 5 above [ ] these minors only:
11
[ ] Restrain respondent from interfering with my physical or legal custody of [ ] the
minors named in paragraph 5 above [ ] these minors only:
12
[ ] Restrain the respondent from removing from the state: [ ] the minors named in
paragraph 5 above [ ] these minors only:
Additional Requests:
13
[ ] Direct the respondent to participate in appropriate treatment or counseling services.
14
[ ]
Require
the respondent to pay the fees and costs of this action.
15
[ ] Remain Effective longer than one year because respondent is likely to resume acts
of domestic violence against me if the order expires in a year.
Protection involving pets.
Petition for Order for Protection (PTORPRT) - Page 4 of 7
WPF DV-1.015 Mandatory (07/2019) - RCW 26.50.030
16
[ ] Grant me exclusive custody and control of the following pet(s) owned, possessed,
leased, kept, or held by me, respondent, or a minor child residing with either me or the
respondent. (Specify name of pet and type of animal.):
____________________________________________________________.
17
[ ] Prohibit respondent from interfering with my efforts to remove the pet(s) named
above.
18
[ ] Prohibit respondent from knowingly coming within, or knowingly remaining within
_______________ (distance) of the following locations where the pet(s) are regularly
found:
[ ] petitioner's residence (You have a right to keep your residential address confidential.)
[ ] ___________________________________________ Park
[ ] other:______________________________________________________
Protection from Firearms and Other Dangerous Weapons
19
[ ] Require the respondent to surrender all firearms, other dangerous weapons, and any
concealed pistol licenses, and prohibit the respondent from accessing, obtaining, or
possessing firearms, other dangerous weapons, or concealed pistol licenses.
Notice: If you are the respondent’s intimate partner, after actual notice and an opportunity to
be heard at the hearing, the court may be required to order the respondent to surrender
firearms, other dangerous weapons, or concealed pistol licenses.
I want emergency temporary protection effective immediately, that lasts
(up to 14 days) until the court hearing:
[ ] An emergency exists as described below. I request that a Temporary Order for
Protection granting the relief requested above in 1) through 12) be issued immediately,
without prior notice to the respondent, to be effective until the hearing.
[ ] I also request temporary surrender all firearms, other dangerous weapons, and any
concealed pistol licenses without notice to the other party because irreparable injury
could result if an order is not issued until the hearing.
What irreparable harm would result if an order is not issued immediately without prior notice
to the respondent?
Request for Special Assistance from Law Enforcement Agencies:
I request the court order the appropriate law enforcement agency to assist me in obtaining:
[ ] Possession of my residence. [ ] Possession of the vehicle designated above.
[ ] Possession of my essential personal belongings at [ ] the shared residence
[ ] respondent’s residence
[ ] other location _______________________________________________________.
Petition for Order for Protection (PTORPRT) - Page 5 of 7
WPF DV-1.015 Mandatory (07/2019) - RCW 26.50.030
[ ] Custody of [ ] the minors named in paragraph 5 above [ ] these minors only (if
applicable):
.
[ ] Other: .
“Domestic violence” means physical harm, bodily injury, assault, including sexual
assault, stalking, Or inflicting fear of imminent physical harm, bodily injury or assault
between family or household members.
Statement: The respondent has committed acts of domestic violence as follows. (Describe
specific acts of domestic violence and their approximate dates, beginning with the most recent
act. You may want to include police responses.)
Describe the most recent violent act, fear or threat of violence, and why the temporary order
should be entered today without notice to the respondent:
.
Describe the past incidents where you experienced violence, where you were afraid of injury or
where the respondent threatened to harm or kill you:
Petition for Order for Protection (PTORPRT) - Page 6 of 7
WPF DV-1.015 Mandatory (07/2019) - RCW 26.50.030
.
Describe any violence or threats towards children:
.
Describe any stalking behavior by respondent, including use of telephonic, audiovisual or
electronic means to harass or monitor:
Describe medical treatment you received and for what:
Describe any threats of suicide or suicidal behavior by the respondent:
Does the respondent own or possess firearms? [ ] Yes [ ] No
Does the respondent use firearms, weapons or objects to threaten or harm you? Please
describe:
.
Has the respondent used, displayed, or threatened to use a firearm or other
dangerous weapon in a felony? Please describe on following page:
Petition for Order for Protection (PTORPRT) - Page 7 of 7
WPF DV-1.015 Mandatory (07/2019) - RCW 26.50.030
.
Is the respondent ineligible to poss
ess a firearm under the provisions of RCW 9.41.040?
Please describe:
.
Does possession of a firearm or other dangerous weapon by the respondent present a serious
and imminent threat to public health or safety, or to the health or safety of any individual?
Please describe:
.
If you are requesting that the protection order lasts longer than one year, describe the reasons
why:
.
Other:
.
(Continue on separate page if necessary.)
Check box if substance abuse is involved: [ ] alcohol [ ] drugs [ ] other
[ ] Personal service cannot be made upon respondent within the state of Washington.
I declare under penalty of perjury under the laws of the state of Washington that the foregoing
is true and correct.
Dated: at , Washington.
Signature of Petitioner
You have a right to keep your residential address confidential. If you have one, please provide
an address, other than your residence, where you may receive legal documents:
.
PETITION FOR ORDER FOR PROTECTION - Statement page ____ of ____.
(9/2000) - RCW 26.50.030
STATEMENT: (Continued)
(Continue on separate page if necessary)
I certify under penalty of perjury under the laws of the state of Washington that the foregoing
is true and correct.
DATED at Washington.
Signature of Petitioner
CHILD CUSTODY INFORMATION SHEET - Page 1 of 2
WPF DV-1.030 (9/2001) - RCW 26.050.030, 26.27.201 – .291
CHILD CUSTODY INFORMATION SHEET NO: ______________________________
If you are seeking protection for your child(ren) from domestic violence or are requesting custody of
your child(ren), please answer the questions and provide the information requested in paragraphs A –E
below and check the boxes about the court's jurisdiction that apply to your case:
Information for the courts:
A. Do the child(ren) listed in Paragraph 5 of the petition currently live with you? If not,
with whom do the child(ren) currently live?
Yes No
B. Do you know of any other court cases involving the child(ren)? If known, list:
the court the case number the kind of case
Yes No
C. Have you been involved in any other litigation concerning custody or visitation with the
child(ren) in this or any other state? If known, list the court, the case number and the
date the parenting plan, residential schedule, visitation schedule or custody decree was
entered:
the court the case number the date
Yes No
D. Do you know of any persons, other than you and the respondent, who claims rights of
custody or visitation with, the child(ren)? If known, list their names in the space
provided below and their present addresses in the Confidential Information Form:
Name
Name
Name
Yes No
E. List the places where the children have lived during the past five years, the dates they lived there and the
persons with whom they lived. (The present addresses of those persons must be listed in the required
Confidential Information Form.)
Jurisdiction:
This court has jurisdiction over this proceeding for the reasons below: [Check all the boxes that apply to
your case.]
This court has exclusive continuing jurisdiction. The court has made a child custody, parenting
plan, residential schedule or visitation determination in this matter before and retains jurisdiction
under RCW 26.27.211.
CHILD CUSTODY INFORMATION SHEET - Page 2 of 2
WPF DV-1.030 (9/2001) - RCW 26.050.030, 26.27.201 – .291
This state is the home state of the children because:
the children lived in Washington with a parent or a person acting as a parent for at least six
consecutive months immediately before the beginning of this proceeding.
the children are less than six months old and have lived in Washington with a parent or a
person acting as parent since birth.
any absences from Washington have been only temporary.
Washington was the home state of the children within six months before the beginning of this
proceeding and the children are absent from the state; but a parent or person acting as a
parent continues to live in this state.
The children and the parents, or the children and at least one parent or a person acting as a parent,
have significant connections with this state other than mere physical presence; and substantial
evidence is available in this state concerning the children’s care, protection, training and personal
relationships and
the children have no home state elsewhere.
the children’s home state has declined to exercise jurisdiction on the ground that this state is
the more appropriate forum under RCW 26.27.261 or 271.
All courts in the children's home state have declined to exercise jurisdiction on the ground that a
court of this state is the more appropriate forum to determine the custody of the children under
RCW 26.27.261 or .271.
No other state has jurisdiction.
This court has temporary emergency jurisdiction over this proceeding because the children are
present in this state and the children have been abandoned, or it is necessary in an emergency to
protect the children because the children, or a sibling or parent of the children is subjected to or
threatened with abuse. RCW 26.27.231.
I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
Dated at , Washington
Petitioner
WPF All Cases 01.0400 LEIS (6/2010) See Reverse For Additional Information
LAW ENFORCEMENT
INFORMATION
Do NOT serve or show this sheet to the restrained person!
Do NOT FILE in the court file. Give this form to law enforcement.
Type or print clearly! This completed form is required by law enforcement. This information is necessary to serve, enforce
and enter your order into the state wide law enforcement computer. Fill in the following information as completely as possible.
Court:
Case Number:
Domestic Violence Dissolution/Separation/Invalidity/Nonparental Custody/Paternity
Unlawful Harassment Vulnerable Adult Sexual Assault
Restrained Person’s Information (This is the person that you want the court to restrain.)
Name: First Middle Last
Nickname
Relationship to Protected Person
Date of Birth
Male
Female
Race
Height
Weight
Eye Color
Hair Color
Skin Tone
Build
Last Known Address
Street:
City: State: Zip:
Phone(s) w/Area Code
Need Interpreter?
Language:
Employer
Employer's Address
WORK
Hours:
Phone: ( )
Vehicle License Number
Vehicle Make and Model
Vehicle Color
Vehicle Year
Drivers License or ID number
State
Does the restrained person have a disability, brain injury, or impairment requiring special assistance when law enforcement
serves the order?
No Yes. If yes, describe (continue on back, if needed):
Hazard Information Restrained Person’s History Includes:
Involuntary/Voluntary Commitment Suicide Attempt or Threats
Assault Assault with Weapons Alcohol/Drug Abuse Other:
Weapons: Handguns Rifles Knives Explosives Other:
Location of Weapons: Vehicle On Person Residence Describe in detail:
Current Status
Are you and the restrained person living together now?
Is the restrained person a current or former cohabitant as an intimate partner?
Does the restrained person know he/she may be moved out of the home?
Does the restrained person know you’re trying to get this order? Is the restrained person likely to react violently when served?
Protected Person’s Information (This is the person you want the court to protect.)
Name: First Middle Last
Date of Birth
Male
Female
Race
Height
Weight
Eye Color
Hair Color
Skin Tone
Build
If your information is not confidential, you must enter your address and phone number(s).
Current Address
Street:
City: State: Zip:
Phone(s) w/Area Code
Need interpreter?
Language:
If your information is confidential, you must provide the name, address and phone number of someone willing to be your “contact.”
Contact Name
Contact Address
Contact Phone
If you filed for someone else,
list your name, phone number
and address:
Minor’s Information
Describe the minor’s relationship using terms such
as: child, grandchild, stepchild, nephew, none.
Minor’s Relationship to
Protected Restrained
Name: First Middle Last
Sex
Race
Birth date
Resides With
Person
Person
Victim’s Household Members or Adult Children Protected
Name: birth date:
Name: birth date:
Name: birth date:
RCW 26.23.050; 26.50.160; GR 22
Mandatory Form (05/2016)
FL All Family 001
Confidential Information
p. 1 of 2
Confidential Information (CIF)
Clerk: Do not file in a public access file
DISTRICT Court of Washington, County: Kittitas
Case No.:
Important! Only court staff and some state agencies may see this form. The other party and
his/her lawyer may not
see this form unless a court order allows it. State agencies may disclose
the information in this form according to their own rules.
1. Who is completing this form? (Name):
2. Is there a current restraining or protection order involving the parties or children? Yes No
If Yes, who does the order protect? (Name/s):
3. Does your address information need to be confidential to protect your or your children’s health,
safety, or liberty? (Check one):
Yes No
If Yes, explain why?
4. Your Information
Full name (first, middle, last):
Date of birth (
MM
/
DD
/
YYYY
):
Sex:
M F
Driver’s license/Identicard (#, state):
Race:
Relationship to children in this case:
Mailing address (This address will not be kept private.) (street address or PO box, city, state zip):
If your case is only about a protection order, the information below is not required. Skip to 5.
Home address (check one): same as mailing address listed below (street, city, state, zip):
Phone:
Email:
Social Sec. #:
Employer’s name:
Employer’s phone:
Employer’s address:
5. Other Party’s Information – This person is a (check one): Petitioner Respondent
Full name (first, middle, last):
Date of birth (
MM
/
DD
/
YYYY
):
Sex:
M F
Driver’s license/Identicard (#, state):
Race:
Relationship to children in this case:
Mailing address (This address will not be kept private.) (street address or PO box, city, state zip):
If your case is only about a protection order, the information below is not required. Skip to 6.
Home address (check one): same as mailing address listed below (street, city, state, zip):
Phone:
Email:
Social Sec. #:
Employer’s name:
Employer’s phone:
Employer’s address:
RCW 26.23.050; 26.50.160; GR 22
Mandatory Form (05/2016)
FL All Family 001
Confidential Information
p. 2 of 2
Skip sections
6
–
9
if your case does not involve children. Sign at the end.
6. Children’s Information (You do not have to fill out the children’s Social Security numbers if your
case is only about a protection order.)
Child’s full name
(first, middle, last)
Date of birth
(MM/DD/YYYY)
Race
Sex
Soc. Sec. #
Current location: lives with
1.
M
F
Petitioner Respondent
other:
2.
M
F
Petitioner Respondent
other:
3.
M
F
Petitioner Respondent
other:
4.
M
F
Petitioner Respondent
other:
5.
M
F
Petitioner Respondent
other:
6.
M
F
Petitioner Respondent
other:
7. Have the children lived with anyone other than Petitioner or Respondent during the last
five years?
(Check one): No Yes If Yes, fill out below:
Children lived with (name)
That person’s current address
1.
2.
8. Do other people (not parents) have custody or visitation rights to the children?
(Check one): No Yes If Yes, fill out below:
Person with rights (name)
That person’s current address
1.
2.
9. If you are asking for custody and are not the parent, list all other adults living in your home:
1. (Name):
Date of birth (MM/DD/YYYY):
2. (Name):
Date of birth (MM/DD/YYYY):
I declare under penalty of perjury under Washington State law that the information on this form about me
is true. The information about the other party is the best information I have or is unavailable because
(explain):
Check here if you need more space to list other Petitioners, Respondents, or children. Put that information
on the Attachment to Confidential Information, form FL All Family 002, and attach it to this form.
Signed at (city and state): Date:
Petitioner/Respondent signs here Print name here
RCW 26.23.050
Mandatory Form (05/2016)
FL All Family 002
Attachment to Confidential Information
(Additional Parties or Children)
p. 1 of 1
Attachment to
Confidential Information
(Additional Parties or Children)
(AT)
Clerk: Do not file in a public access file
County: KITTITAS
Case No.:
Use this form if there are more parties or children in your case than you can list on the Confidential Information form.
1. Other Party’s Information (if any) – This person is a (check one): Petitioner Respondent
Full name (first, middle, last):
Date of birth (
MM
/
DD
/
YYYY
):
Sex:
M F
Driver’s license/Identicard (#, state):
Race:
Relationship to children in this case:
Mailing address (This address will not be kept private.) (street address or PO box, city, state zip):
If your case is only about a protection order, the information below is not required. Skip to 2.
Home address (check one): same as mailing address listed below (street, city, state, zip):
Phone:
Email:
Social Sec. #:
Employer’s name:
Employer’s phone:
Employer’s address:
2. Other Party’s Information (if any) – This person is a (check one): Petitioner Respondent
Full name (first, middle, last):
Date of birth (
MM
/
DD
/
YYYY
):
Sex:
M F
Driver’s license/Identicard (#, state):
Race:
Relationship to children in this case:
Mailing address (This address will not be kept private.) (street address or PO box, city, state zip):
If your case is only about a protection order, the information below is not required. Skip to 3.
Home address (check one): same as mailing address listed below (street, city, state, zip):
Phone:
Email:
Social Sec. #:
Employer’s name:
Employer’s phone:
Employer’s address:
3. Other Children’s Information (if any) (You do not have to fill out the children’s Social Security
numbers if your case is only about a protection order.)
Child’s full name
(first, middle, last)
Date of birth
(MM/DD/YYYY)
Race
Sex
Soc. Sec. #
Current location: lives with
7.
M
F
Petitioner Respondent
other:
8.
M
F
Petitioner Respondent
other:
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Instructions for Petition for Order for Protection (Kittitas County WA)

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Completed 30 July 2020

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