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Request For Elder Or Dependent Adult Abuse Restraining Orders EA-100 - California
| Request For Elder Or Dependent Adult Abuse Restraining Orders Form. This is a California form and can be used in Elder Or Dependent Adult Abuse Judicial Council . |
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EA-100 Request for Elder or Dependent Adult Abuse Restraining Orders Clerk stamps date here when form is filed. Read Can an Elder or Dependent Adult Abuse Restraining Order Help Me? (Form EA-100-INFO) before completing this form. Also fill out Confidential CLETS Information (Form CLETS-001), with as much information as you know. 1 Elder or Dependent Adult in Need of Protection Full Name: Sex: M F Age: Fill in court name and street address: 2 Person From Whom Protection Is Sought Full Name: Address (if known): City: State: Zip: Superior Court of California, County of 3 Person Requesting Order Who is asking the court for protection? (Check a, b, or c): a. The elder or dependent adult named in 1 . b. Name: conservator of the person estate person and estate of the person named in 1 , appointed by (name of court): Case No.: c. Other (name): Court fills in case number when form is filed. Case Number: (Show this person's legal authority to make this request on an attached sheet of paper. Write "Attachment 3c --Information About Person Requesting Protective Order" for a title. You may use Form MC-025, Attachment.) 4 Contact Information Contact information for the person asking the court for protection: a. Your Lawyer (if you have one for this case): Name: State Bar No: Firm Name: Your Address (If you have a lawyer, give your lawyer's information. If you do not have a lawyer and you want to keep your home address private, you may give a different mailing address instead. The person in 1 does not have to give telephone, fax, or e-mail.): Address: City: Telephone: E-Mail Address: State: Fax: Zip: b. This is not a Court Order. Judicial Council of California, www.courts.ca.gov Revised January 1, 2012, Mandatory Form Welfare & Institutions Code, § 15657.03 Code of Civil Procedure, § 527.9 Request for Elder or Dependent Adult Abuse Restraining Orders (Elder or Dependent Adult Abuse Prevention) EA-100, Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: 5 Description of Protected Person Describe the person named in 1 . (Check a or b): Is age 65 or older and a resident of California. a. b. Is a resident of California and an adult under age 65. This person has physical or mental limitations that restrict his or her ability to carry out normal activities or to protect his or her rights. (Briefly describe limitations on the attached sheet of paper or Form MC-025. Write "Attachment 5--Description of Protected Person" for a title.) 6 Additional Protected Persons a. Are you asking for protection for any other family or household members or for the conservator of the elder or dependent adult listed in 1 ? Yes No If yes, list them: Full Name Sex Age Lives with you? How are they related to you? Yes Yes Yes Yes No No No No Check here if there are more persons. Provide the above information for each one on the attached sheet of paper or MC-025. Write "Attachment 6a--Additional Protected Persons" for a title. b. Why do these people need protection? (Explain below): Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of paper or Form MC-025 and write "Attachment 6b--Why Others Need Protection" for a title. 7 Relationship of Parties How does the person in 1 know the person in 2 ? (Explain below): Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of paper or Form MC-025 and write "Attachment 7--Relationship of Parties" for a title. 8 Venue Why are you filing in this county? (check all that apply): a. b. c. The person in 2 lives in this county. The person in 1 was abused by the person in 2 in this county. Other (specify): Revised January 1, 2012 This is not a Court Order. Request for Elder or Dependent Adult Abuse Restraining Orders (Elder or Dependent Adult Abuse Prevention) EA-100, Page 2 of 7 Case Number: 9 Other Court Cases a. Has the person in 1 or any of the persons named in 6 been involved in another court case with the person in 2? No Yes (If yes, specify the kind of each case and indicate where and when each was filed:) Kind of Case (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) Elder or Dependent Adult Abuse Civil Harassment Domestic Violence Divorce, Nullity, Legal Separation Paternity, Parentage, Child Custody Eviction Guardianship Workplace Violence Small Claims Criminal Other (specify): Filed in (County/State) Year Filed Case Number (if known) b. Are there now any protective or restraining orders in effect relating to the person in 1 or any of the persons named in 6 and the person in 2 ? No Yes If yes, attach a copy if you have one. 10 Description of Abuse a. Abuse means either: (1) Physical abuse, neglect, financial abuse, abandonment, isolation, abduction, or other treatment with resulting physical harm or pain or mental suffering; or (2) The withholding by a caretaker of goods or services that are necessary to avoid physical harm or mental suffering. b. Tell the court about the last time the person in 2 abused the person in 1 . (1) When did it happen? (provide date or estimated date): (2) Who else was there? (3) Describe what happened below. Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of paper or Form MC-025 and write "Attachment 1-b(3)--Describe Abuse" for a title. (4) Was the abuse solely financial abuse unaccompanied by force, threat, harassment, intimidation, or any other form of abuse? Yes, only financial abuse. No, the abuse included other forms of abuse described above. This is not a Court Order. Revised January 1, 2012 Request for Elder or Dependent Adult Abuse Restraining Orders (Elder or Dependent Adult Abuse Prevention) EA-100, Page 3 of 7 Case Number: (5) Did the person in 2 use or threaten to use a gun or any other weapon? Yes No (If yes, explain below): Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of paper or Form MC-025 and write "Attachment 10b(5)--Use of Weapons" for a title. (6) Was the person in 1 harmed or injured as a result of the acts of abuse described above? Yes No (If yes, explain below): Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of paper or Form MC-025 and write "Attachment 10b(6)--Harm or Injury" for a title. (7) Did the police come? Yes No If yes, did they give the person in 1 or the person in 2 an Emergency Protective Order? If yes: The order protects (check all
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