Fill - Free fillable STATE OF GEORGIA Petitioner, : Civil Action File (Cherokee County, Georgia) PDF form

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ORI Number ____________________

SC-16

THE SUPERIOR COURT FOR THE COUNTY OF ________________

STATE OF GEORGIA

_____________________, :

Petitioner, : Civil Action File

v. :

_____________________, : No. _____________________

Respondent. :

FAMILY VIOLENCE TWELVE MONTH PROTECTIVE ORDER

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

continued. Having heard the evidence presented, reviewed the petition and the entire record concerning

this case and for good cause shown, IT IS HEREBY ORDERED AND ADJUDGED:

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 shall be in effect for up to twelve (12) months from

______________________, 20_____ until ______________________, 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, 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.

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CIVIL ACTION FILE NO. _____________________

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.

ONLY THE FOLLOWING THAT ARE INITIALED BY THE JUDGE SHALL APPLY:

_____ 7. Petitioner is awarded sole and exclusive possession of the residence at ____________

[pco03] _____________________________________________________________________.

_____ 8. Respondent is ordered to leave the family residence immediately and law enforcement at

__________________ (sheriff or police department) is ordered to assist Petitioner in

returning to the family residence and the removal of the Respondent. Respondent shall

immediately surrender to law enforcement __________________ (sheriff or police

department) all and any keys, garage door openers and other security devices to the

family residence and law enforcement shall ensure that these are given to the Petitioner.

_____ 9. 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.

_____ 10. Respondent is ordered to provide suitable alternate housing for Petitioner and/or

Petitioner’s children by ______________________, 20_____.

_____ 11. That Respondent is restrained and enjoined from approaching within __________ yards

[pco01,04] of Petitioner and/or Petitioner’s minor children.

_____ 12. 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.

_____ 13. That Petitioner is awarded temporary custody of the minor child/ren, namely:

[pco09] __________________________________ 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.

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CIVIL ACTION FILE NO. _____________________

_____ 14. The _______________ shall pay to the _______________, for the support of the minor

child/ren, the sum of _________________________________ Dollars ($___________)

per ___________________________, beginning ______________________, 20_____.

All payments are to be made by or to: ____ income deduction order

____ child support receiver

____ by mail directly to the Petitioner

or ____ _____________________________

_____ 15. Respondent is ordered to pay temporary support for the Petitioner in the amount of

$___________ every ___________________ beginning ______________________,

20_____.

All payments are to be made by or to: ____ income deduction order

____ child support receiver

____ by mail directly to the Petitioner

or ____ _____________________________

_____ 16. Respondent shall have visitation with the minor child/ren according to the following

schedule, beginning ________________________________________:

____ no visitation

____ no visitation until______________________, 20_____.

____ supervised visitation, supervised by a third party as follows:

____________________________________________________________

____ visitation every other weekend from Friday at 6 p.m. until Sunday at 6 p.m

beginning________________________________, ___________

____ 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.

_____ 17. Respondent, only when accompanied by local law enforcement, shall be able to

remove his/her clothing and personal items from the residence as follows:

______________________________________________________________________

On ______________________, 20_____ at ____.m.

_____ 18. (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

business.

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CIVIL ACTION FILE NO. _____________________

_____ 19. (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.

_____ 20. Petitioner shall have sole, exclusive temporary possession of the vehicle:

Make ________________ Model ________________ Year ____ Color ____________.

Respondent shall immediately surrender all keys, proof of insurance, and registration to

this vehicle to law enforcement, and law enforcement shall immediately turn over said

items to Petitioner.

_____ 21. Petitioner shall be allowed to remove the following property from the family residence

for Petitioner and/or Petitioner’s child/ren’s use: _______________________________

______________________________________________________________________

______________________________________________________________________.

On ___________________, 20_____ at ____ and law enforcement ______________

(sheriff or police department) is hereby ordered to assist the Petitioner during this

removal.

_____ 22. Respondent is ordered to undergo alcohol/drug abuse evaluation and follow the

recommended treatment.

_____ 23. That Respondent shall be required to return the following property for

Petitioner and/or Petitioner’s child/ren’s use: ________________________________

______________________________________________________________________

On __________________, 20_____ at ____.m. and law enforcement_______________

(sheriff or police department) is hereby ordered to assist the Petitioner during this return.

_____ 24. Petitioner is awarded costs and attorney fees in the amount of _______________.

_____ 25. FAMILY VIOLENCE INTERVENTION PROGRAM

It is further Ordered that the Respondent shall make arrangements to begin a

certified family violence intervention program (FVIP) within fourteen (14) days of the

signing of this Order, or if appropriate within fourteen (14) days upon release from

incarceration. A list of local certified agencies will be given to the Respondent with this

Order. Furthermore, Respondent shall appear before this court ___________________,

20_____ at .m. for a hearing on the status of his/her application, attendance

and/or completion of the FVIP. At that hearing, Respondent is ordered to present to this

court a written status report from the agency providing the certified FVIP. The status

report shall detail Respondent’s application, attendance and/or completion of or failure

to apply, attend and/or complete the FVIP and shall be signed by an officer of the

agency.

OR

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CIVIL ACTION FILE NO. _____________________

_____ Respondent is ordered to undergo a certified family violence intervention program and

comply with the attached compliance form.

OR

_____ Respondent is ordered to undergo a certified family violence intervention program.

OR

_____ Respondent is not ordered to undergo a certified family violence intervention program

and the following reasons exist:

______________________________________________________________________

_____ 26. 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).

_____ 27. It is further Ordered:

[pco08] _________________________________________________________________

__________________________________________________________________

SO ORDERED this _______ day of ______________________, 20_____.

_____________________________

JUDGE, SUPERIOR COURT

_______________________ County

_____________________________

Print or stamp Judge’s name

Violation of the above Order may be punishable by arrest.

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CIVIL ACTION FILE NO. __________________

NOTICE TO RESPONDENT

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 superceded 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.

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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.

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CIVIL ACTION FILE NO. _____________________

*REMOVE THIS PAGE FROM ORDER AND FILE SEPARATELY UNDER SEAL*

*For transmittal to the Georgia Protective Order Registry and, if applicable,

the National Crime Information Center.*

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 ______________



Transmitted to Georgia Protective Order Registry Date __________ Clerk ___________________________

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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