ORI Number ____________________
_____________________, :
Petitioner, : Civil Action File
v. :
_____________________, : No. ________________
Respondent. :
A hearing was held on this matter on ______________________, 20_____ for which the
Respondent had notice as required by law and at which the Respondent appeared and/or had the
opportunity to be heard and the Petitioner requested that the Protective Order entered in this case be
converted to a Permanent Family Violence Protective Order. This Court has determined that it had
jurisdiction over the subject matter and the parties. Having heard the evidence presented, reviewed the
Motion and the entire record concerning this case and for good cause shown, IT IS HEREBY
1. That these proceedings be filed in the office of the Clerk of this Court.
2. That this Order applies in every county throughout the state and it shall be the duty of
every court and every law enforcement official to enforce and carry out the provisions
of this Order pursuant to O.C.G.A. § 19-13-4 (d). Law enforcement officers may use
their arrest powers pursuant to O.C.G.A. §§ 19-13-6 and 17-4-20 to enforce the terms of
this Order.
3. This Order and the Order issued ______________________, 20_____ shall be
permanent pursuant to O.C.G.A. § 19-13-4 (c) and have NO expiration date.
3.1 This Order shall be in effect for three (3) years and shall expire on
______________________, 20_____.
4. That the Respondent has violated the Family Violence Act, O.C.G.A. § 19-13-1
[pco01] et seq., by committing family violence, has placed the Petitioner in reasonable
fear for Petitioner’s safety, and represents a credible threat to the physical safety of
Petitioner and/or Petitioner’s child/ren. Respondent is hereby enjoined and restrained
from doing, or attempting to do, or threatening to do, any act of injury, maltreating,
molesting, following, harassing, harming, or abusing the Petitioner and/or the minor
child/ren in any manner. Respondent is not to interfere with Petitioner’s travel,
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CIVIL ACTION FILE NO. _____________________
transportation, or communication. Respondent shall not follow, place under
surveillance, or contact the Petitioner at any place of the Petitioner for the purpose of
harassing and intimidating the Petitioner.
5. That the Respondent is enjoined and restrained from doing or attempting to do, or
[pco02] threatening to do, any act of injury, maltreating, molesting, harassing, harming, or
abusing the Petitioner’s family or household.
6. That this Court determined that it had jurisdiction over the parties and the subject matter
under the laws of the State of Georgia and Respondent received reasonable notice and
had the opportunity to be heard before this Order was issued sufficient to protect the
Respondent’s due process rights and this Order shall be presumed valid and pursuant to
18 U.S.C. § 2265(a) shall be accorded full faith and credit by any other state or local
jurisdiction and shall be enforced as if an Order of the enforcing state or jurisdiction.
_____ 7. Respondent is ordered to stay away from Petitioner’s and Petitioner’s child/ren’s
[pco04] residence and workplace and/or school and any subsequent residence or workplace or
school of Petitioner and/or Petitioner’s minor child/ren.
_____ 8. That Respondent is restrained and enjoined from approaching within __________ yards
[pco01,04] of Petitioner and/or Petitioner’s minor children.
_____ 9. Respondent is ordered not to have any contact, direct, indirect or through another
[pco05] person with Petitioner, by telephone, fax, e-mail or any other means of communication
except as specified in this Order.
_____ 10. That Petitioner is awarded custody of the minor child/ren, namely:
[pco09] __________________________________ YOB ____________ sex __________
__________________________________ YOB ____________ sex __________
__________________________________ YOB ____________ sex __________
__________________________________ YOB ____________ sex __________
Respondent is ordered not to interfere with the physical custody of the minor child/ren.
_____ [pco06] Initial here only if Respondent is awarded temporary custody of the child/ren.
_____ 11. The _______________ shall pay to the _______________, for the support of the minor
child/ren, the sum of _________________________________ Dollars ($___________)
per ___________________________, beginning ______________________, 20_____.
CIVIL ACTION FILE NO. _____________________
All payments are to be made by or to: ____ income deduction order
____ child support receiver
____ by mail directly to the Petitioner
or ____ _____________________________.
In determining child support the Court finds as follows:
The Father’s gross monthly income (before taxes) is $____________________;
The Mother’s gross monthly income (before taxes) is $____________________.
Number of children The number of children for whom support is being provided
under this order is ____________________.
( ) It has been determined that none of the Deviations allowed under O.C.G.A § 19-6-
15 applies in this case. OR
( ) It has been determined that one or more of the Deviations allowed under O.C.G.A.
§ 19-6-15 applies in this case, as shown by the attached Schedule E. The Presumptive
Amount of Child Support that would have been required under O.C.G.A § 19-6-15 if
the deviations had not been applied is $____________________ per month, as shown
on the attached Child Support Worksheet. The attached Schedule E explains the reasons
for the deviation, how the application of the guidelines would be unjust or inappropriate
considering the relative ability of each parent to provide support, and how the best
interest of the child/ren who is/are subject to this child support determination is served
by deviation from the presumptive amount of child support.
The Child Support Order Addendum is attached and made a part of this Order.
_____ 12. Respondent is ordered to pay temporary support for the Petitioner in the amount of
$___________ every ___________________ beginning ________________________.
All payments are to be made by or to: ____ income deduction order
____ child support receiver
____ by mail directly to the Petitioner
or ____ _____________________________.
_____ 13. Respondent shall have visitation with the minor child/ren according to the following
schedule, beginning ______________________, 20_____:
____ no visitation
____ no visitation until _____________________________________
____ supervised visitation, supervised by a third party as follows:
CIVIL ACTION FILE NO. _____________________
____ visitation every other weekend from Friday at 6 p.m. until Sunday at 6 p.m
beginning ______________________, 20_____.
____ other visitation _______________________________________________
____ circumstances concerning how Respondent shall pick up and return the
minor child/ren shall be ________________________________________
Strict compliance with this visitation provision shall not be a violation of the restraining
provisions of this Order.
_____ 14. (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate]
is/are ordered not to sell, encumber, trade, damage, contract to sell, or otherwise dispose
of or remove from the jurisdiction of this Court any of the property or pets of the
Petitioner or joint property or pets of the parties except in the ordinary course of
_____ 15. (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate]
is/are ordered not to disconnect or have disconnected home utilities, change or have
changed and/or cancel or have canceled auto, health or life insurance for Respondent,
Petitioner, and/or Petitioner’s child/ren or interfere with Respondent, Petitioner’s and/or
Petitioner’s child/ren’s mail.
_____ 16. Petitioner is awarded costs and attorney fees in the amount of $ _____________.
_____ 17. Petitioner/protected party is either a spouse, former spouse, parent of a common
[pco07] child, Petitioner’s child, child of Respondent, cohabitates or has cohabited with
Respondent and qualifies for 18 U.S.C. §922(g). It is further ordered that the
Respondent shall not possess or purchase a firearm or ammunition as restricted by
federal law under 18 U.S.C. § 922(g)(8).
_____ 18. It is further Ordered:
[pco08] ______________________________________________________________________
SO ORDERED this _______ day of ______________________, 20_____.
_______________________ County
Print or stamp Judge’s name
Violation of the above Order may be punishable by arrest.
CIVIL ACTION FILE NO. _____________________
1. Violation of this Order may result in immediate arrest and criminal prosecution that may result in
jail time and/or fines and/or may subject you to prosecution and penalties for contempt of court.
2. This Order shall remain in effect unless specifically superseded by a subsequent Order signed and
filed, by operation of law, or by Order of dismissal, whichever occurs first. Only this Court can void,
modify or dismiss this Order. Either party may ask this Court to change or dismiss this Order.
3. If after a hearing, of which the Respondent received notice and opportunity to participate, a
protective order is issued which restrains Respondent from harassing, stalking or threatening an
intimate partner, Respondent is prohibited from possessing, receiving, or transporting a firearm or
ammunition which has been shipped or transported in interstate or foreign commerce for the duration
of the Order. 18 U.S.C. § 922(g).
4. A person commits the offense of Aggravated Stalking when such person, in violation of a temporary
or permanent protective Order prohibiting this behavior, follows, places under surveillance, or contacts
another person on public or private property for the purpose of harassing and intimidating the other
person. This activity can subject the Respondent to arrest and prosecution for Felony Aggravated
Stalking, which carries penalties of imprisonment for not less than 1 year nor more than 10 years and a
fine of up to $10,000.00.
CIVIL ACTION FILE NO. _____________________
Pursuant to O.C.G.A. § 19-13-3,
Petitioner assisted by
Name: _____________________________
Address: ___________________________
Telephone: _________________________
Note to Judges: This form is promulgated as a Uniform Superior Court Rule under the auspices of
O.C.G.A. § 19-13-53. To order a specific provision, please initial in the space provided. The court
should delete or otherwise make inoperative any provision in the standardized form which is not
supported by the evidence in the case and in order to comply with the court´s application of the law
and facts to an individual case.
CIVIL ACTION FILE NO. _____________________
*For transmittal to the Georgia Protective Order Registry and, if applicable,
the National Crime Information Center.*
(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: ____________________________.
Petitioner: _________________________ DOB ___________ sex _______ race ______________
Other: _________________________ DOB ___________ sex _______ race ______________
Other: _________________________ DOB ___________ sex _______ race ______________
Other: _________________________ DOB ___________ sex _______ race ______________
Other: _________________________ DOB ___________ sex _______ race ______________
Transmitted to Georgia Protective Order Registry Date __________ Clerk ___________________________
Rev’d 8/14
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