California > Local County > Sacramento > Family Law
Petition For Protective Orders Elder Or Dependent Adult Abuse - California
| Petition For Protective Orders Elder Or Dependent Adult Abuse Form. This is a California form and can be used in Family Law Sacramento Local County . |
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Attachment to Application For PETITION FOR PROTECTIVE ORDERS (Elder or Dependent Adult Abuse) Allegations of Abuse 1. The most recent incident of PHYSICAL abuse by the Defendant was ________________________________. (approx. date) Defendant: ! hit me on the: ! arms ! legs ! face ! head ! stomach ! back ! eye ! black eye ! kicked me on the _______________________________________________________________. ! pushed and/or shoved me: ! into wall ! to the floor ! threatened me with a weapon (specify weapon and describe incident): ____________________________________________________________________________. ! pulled me by my hair ! choked me ! bruises; describe: ______________________________________________________________. ! City Police/Sheriff was called; ! Defendant was arrested for spousal abuse ! Report taken ! Other injuries: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________ 2. The second most recent incident of PHYSICAL abuse by the Defendant was ____________________________. (approx. date) Defendant: ! hit me on the: ! arms ! legs ! face ! head ! stomach ! back ! eye ! black eye ! kicked me on the _______________________________________________________________. ! pushed and/or shoved me: ! into wall ! to the floor ! threatened me with a weapon (specify weapon and describe incident): ______________________________________________________________________________ ! pulled me by my hair ! choked me ! bruises; describe:________________________________________________________________ ! City Police/Sheriff was called; ! Defendant was arrested for spousal abuse ! Report taken ! Other 2001 © American LegalNet, Inc. injuries:__________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ _________________________________________________________________________________ PLEASE COMPLETE INFORMATION ON REVERSE 3. The third most recent incident of PHYSICAL abuse by the Defendant was ______________________________. Defendant: ! hit me on the: ! arms eye ! kicked me on the ________________________________________________________________. ! pushed and/or shoved me: ! into wall ! to the floor ! threatened me with a weapon (specify weapon and describe incident): _______________________________________________________________________________ ! pulled me by my hair ! choked me ! bruises; describe:________________________________________________________________ ! City Police/Sheriff was called; ! Defendant was arrested for spousal abuse ! Report taken ! Other injuries:________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 4. Since the last act of violence, explain the delay, if any, in seeking this restraining order: ____________________________________________________________________________________ ____________________________________________________________________________________ ______________ ____________________________________________________________________________________ _______ ! legs ! face ! head (approx. date) ! stomach ! back ! eye ! black 2001 © American LegalNet, Inc. 5. The most recent incident of threats to ! kill me; ! beat me; was on_____________________. (approx. date) He/She said_________________________________________________________________________________ ____________________________________________________________________________________ ______. 8. Other past incidence of physical abuse:__________________________________________________________ ____________________________________________________________________________________ ______ ____________________________________________________________________________________ ______ ____________________________________________________________________________________ ______ I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: ........................................ (type or print name) _______________________________________________ (signature of person to be protected) Revised 12//00 2001 © American LegalNet, Inc.
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