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STATE OF GEORGIA (Cherokee County, Georgia)

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1
SC-26
THE SUPERIOR COURT FOR THE COUNTY OF ________________
STATE OF GEORGIA
______________________, :
Petitioner, : Civil Action File
:
v. :
: No. _____________________
______________________, :
Respondent. :
PETITION FOR TEMPORARY PROTECTIVE ORDER
The Petitioner, pursuant to the Family Violence Act O.C.G.A. § 19-13-1 et seq., files this
Petition for a Family Violence Protective Order and in support shows the Court the following:
1. Petitioner is a resident of ______________ County, Georgia, and is 18 years of
age or older or is an emancipated minor. Petitioner's year of birth is _________ ,
sex ______, and race __________.
2. Respondent is a resident of _____________________ County, Georgia, and may
be served at ______________________________________________________,
Georgia. Jurisdiction and venue are proper with this Court.
OR
2.1 Respondent is a resident of the State of __________________. Under O.C.G.A. §
19-13-2 (b), jurisdiction and venue are proper with this Court because the abuse
occurred in the State of Georgia in ____________ County and/or Petitioner lives
in _____________ County. Respondent is subject to the jurisdiction of this Court
and may be served at ________________________________________________.
3. Petitioner and Respondent are:
____ 1. Present or past spouses
____ 2. Parents of the same child/ren
____ 3. Parent and child/ren
____ 4. Persons who used to live in the same household
____ 5. Persons currently living in the same household
____ 6. Foster parent and foster child
____ 7. Stepparent and stepchild
4. On or about ______________, 20____, Respondent committed the following acts
of family violence against Petitioner and/or the minor child/ren: _____________
_________________________________________________________________
_________________________________________________________________
For your convenience, this form has been designed to be completed
online. The information typed on the first page will automatically
update to the other pages. Please be sure all pertinent information is
completed before printing. Once the form is completed, select 'Print' to
print the form. Selecting 'Reset' will clear the entire form.
Print
Reset
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_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Petitioner is in reasonable fear for Petitioner's own safety and/or the safety of the
minor child/ren.
5. At other times Respondent has committed other such acts, including but not
limited to (approximate dates and what happened):
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
6. There is a substantial likelihood that Respondent will commit such acts of
violence against Petitioner and the minor child/ren in the immediate future if
relief is not granted as provided pursuant to O.C.G.A. § 19-13-4.
Check the paragraphs below that apply to your case. Fill in the information
needed by each paragraph you check.
____ 7. Petitioner and Respondent have ____ child/ren under the age of 18. Their names,
years of birth, sex, and ages are _______________________________________
_________________________________________________________________
_________________________________________________________________
These child/ren have lived only with Petitioner and Respondent for the past five
(5) years. (If the child/ren have not resided only with Petitioner and Respondent
for the last five years, give the names of the persons, their addresses, and the dates
the child/ren resided with them _______________________________________
3
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
____ 8. The parties are not married and Respondent ____________ (has OR has not)
legitimated the child/ren of the parties.
____ 9. Petitioner (does OR does not) have knowledge concerning custody or claims of
custody concerning these child/ren including divorce, separation, juvenile, and
DFCS cases. Specify court and type of case (if applicable) _________________
_________________________________________________________________
____ 10. Petitioner has the following minor child/ren living with Petitioner whom
Petitioner wishes protected from Respondent and including in the Protective
Order (names and ages): _____________________________________________
_________________________________________________________________
_________________________________________________________________
____ 11. Petitioner believes Respondent has a criminal record and has committed the
following crimes (approximate dates and crimes): _________________________
_________________________________________________________________
____ 12. Petitioner fears that if Respondent learns of Petitioner's current address that
Respondent will hurt or injure Petitioner or Petitioner's immediate family.
Petitioner requests that Respondent not be informed of Petitioner's current
residence.
____ 13. Petitioner is dependent upon the family residence for shelter for Petitioner and/or
minor child/ren and asks that Petitioner be granted the temporary use and
possession of said residence, located at ________________________, together
with all personal property contained therein with the exception of Respondent’s
personal clothing.
____ 14. Petitioner and the minor child/ren are dependent upon the Respondent for support
and requests that Petitioner be awarded temporary child support.
____ 15. Petitioner is dependent upon Respondent for support and asks that Petitioner be
awarded temporary support.
____ 16. The minor child/ren are currently in the custody and control of
Petitioner/Respondent and Petitioner asks for legal and physical custody.
____ 17. Petitioner asks that the following assets/property of Petitioner be returned by
Respondent: ______________________________________________________
4
THEREFORE, Petitioner asks:
(a) That the Court set a hearing no later than thirty (30) days from the filing of the
Petition and direct Respondent to appear before this Court and show any reasons
why the demands of the Petitioner should not be granted;
(b) That the Respondent be served a copy of this Petition and Ex Parte Protective
Order as required by law;
(c) That this Court direct law enforcement to enforce this Order;
(d) That this Court direct Respondent to stop abusing, harassing and intimidating
Petitioner and/or Petitioner’s child/ren;
(e) That this Court restrain and enjoin Respondent from having any direct or indirect
contact with the Petitioner and/or Petitioner’s child/ren;
(f) That this Court order that Respondent be enjoined from approaching within
__________ yards of Petitioner;
(g) That this Court make findings of fact and conclusions of law concerning the
issues in this case;
(h) That Petitioner have such other and further relief as the Court may deem just and
proper;
(i) That this Court issue Family Violence Ex Parte and Twelve Month Protective
Orders to:
Check the paragraphs below that apply to your case. Fill in the information
needed by each paragraph you check.
____ award Petitioner temporary sole legal and physical custody of the minor child/ren;
____ order Respondent to vacate the family residence at ______________________________
instanter;
____ grant Petitioner exclusive temporary use and possession of the family residence at
______________________ and all personal property of the parties located at the family
5
residence and Petitioner’s current residence with the exception of Respondent’s personal
clothing; that law enforcement _________ (sheriff or police department) assist Petitioner
in returning to the family residence and in ensuring that the Respondent vacates said
residence and that all keys, garage door openers and other security devices to the family
residence are secured and given to the Petitioner;
____ order Respondent to provide suitable alternate housing for Petitioner and/or Petitioner’s
children;
____ order Respondent to stay away from Petitioner’s and/or Petitioner’s minor child/ren’s
place of residence, place of employment, and/or school;
____ order Respondent’s visitation with the minor child/ren be limited to no visitation or
______________________________________________________________________
______________________________________________________________________ ;
____ order Respondent to pay to Petitioner child support for the minor child/ren;
____ order Respondent to pay spousal support for Petitioner;
____ award Petitioner costs and attorney’s fees for having to bring this action;
____ order that Petitioner’s current address be kept confidential;
____ enjoin and restrain Respondent from selling, disposing or encumbering, trading,
contracting to sell, or otherwise disposing or removing from the jurisdiction of this Court
any of the property of Petitioner or of the parties except in the ordinary course of
business;
____ enjoin and restrain Respondent from disconnecting the home utilities, changing and/or
canceling auto, health or life insurance for Respondent, Petitioner, and/or the Petitioner’s
minor child/ren, and/or interfering with Petitioner’s or the Petitioner’s minor child/ren’s
mail;
____ grant Petitioner the use of the following automobile: Make _____ , Model __________,
Year ________, and law enforcement ______________ (sheriff or police department)
ensure that all keys to said vehicle be immediately returned to Petitioner;
____ permit Petitioner to remove the following property from the residence for the exclusive
use by Petitioner and/or the minor child/ren _________________________________
______________________________________________________________________
______________________________________________________________________
and law enforcement _________________ (sheriff or police department) be ordered to
assist Petitioner during this removal;
6
____ order Respondent to undergo evaluation for drug/alcohol abuse and to follow the
recommended treatment;
____ order Respondent to undergo a batterer’s intervention program and to follow the
recommended treatment;
____ order Respondent to return _________________________________________________
to Petitioner immediately;
____ order Respondent to reimburse Petitioner for damages or expenses for the following:
______________________________________________________________________
____ order additional relief as follows: __________________________________________
______________________________________________________________________
Respectfully submitted,
___________________________________
Petitioner
Address
___________________________________
___________________________________
___________________________________
Telephone: __________________________
(Do not give current address if confidential;
give alternative address)
7
THE SUPERIOR COURT FOR THE COUNTY OF __________________
STATE OF GEORGIA
______________________________ , :
Petitioner, : Civil Action File
:
v. : No. _________________________
:
______________________________ , :
Respondent. :
VERIFICATION
Personally appeared ___________________, who being duly sworn states that she/he is
the Petitioner in the above styled case and that the facts set forth in the foregoing Petition for
Temporary Protective Order are true and correct.
______________________________
Petitioner
Sworn and subscribed before
me this ______ day of _____________ , 20___.
__________________________________
NOTARY PUBLIC
My commission expires:
8
CIVIL ACTION FILE NO. _____________________
Pursuant to O.C.G.A. § 19-13-3,
Petitioner assisted by
Name: ______________________________
Address: ____________________________
____________________________________
Phone: ______________________________
9
*REMOVE THIS PAGE FROM ORDER AND FILE SEPARATELY UNDER SEAL*
RESPONDENT’S IDENTIFYING FACT SHEET
(please complete as much as possible; one of these must be provided to have the order placed in the National Crime
Information Center registry: Respondent’s date of birth OR social security number)
Respondent’s social security number is _________________, date of birth is _________, sex ____, color
of hair __________, color of eyes ______________, height _________, weight _____. Respondent’s
race is __________, ethnic background ____________. Respondent has distinguishing marks (tattoos,
scars, etc.)_____________________. Respondent drives a __________________________, license tag
no:____________(Expires:____) and has a ___(state) driver’s license no: _____________(Expires:____).
Respondent’s home address _____________________________________________ and is employed
by__________________ at _________________________________ and works from ____ to ____ on
(days)___________. Respondent has the following known aliases: ______________________________.
PROTECTED PARTIES’ IDENTIFYING INFORMATION
Petitioner: _________________________ DOB ___________ sex _______ race ______________
Other: _________________________ DOB ___________ sex _______ race ______________
Other: _________________________ DOB ___________ sex _______ race ______________
Other: _________________________ DOB ___________ sex _______ race ______________
Other: _________________________ DOB ___________ sex _______ race ______________
Rev'd 8/14
CONFIDENTIAL INFORMATION FORM - ATTENTION COURT
STAFF: THIS PAGE IS A RESTRICTED-ACCESS DOCUMENT.
This document is not accessible to the public or to other parties.
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STATE OF GEORGIA (Cherokee County, Georgia)

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Completed 23 June 2021

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