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Domestic Violence Restraining Order Incident Summary (Packet Attachment) FL-E-LP-613 - California
| Domestic Violence Restraining Order Incident Summary (Packet Attachment) Form. This is a California form and can be used in Family Law Sacramento Local County . |
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Domestic Violence Packet Attachment to Application For DOMESTIC VIOLENCE RESTRAINING ORDERS Other Case(s) Involving Child Custody and/or Visitation 1. I have/ have not participated in another case against the person who is to be restrained which involves child custody and/or visitation. Name of Court, which heard, or is hearing, action: ________________________________________________. The Court's order or judgment regarding child custody and/or visitation was: ___________________________ _________________________________________________________________________________________. The child (ren) have been living with Mother Father since Partner ____________________________. (approx. date) 2. 3. 4. 5. I have/ have not had an Emergency Protective Order, Criminal Temporary Restraining Order, or Criminal Restraining Order against the person who is to be restrained. Name of the Court and case number which heard, or is hearing the action:________________________________ 6. Are you currently involved in a dependency case? ____ Yes ____No 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 injuries:__________________________________________________________________ ________________________________________________________________________________ Domestic Violence Packet Attachment Page 1 of 2 FL/E-LP-613 (Rev. 1/29/2009) Mandatory American LegalNet, Inc. www.FormsWorkflow.com ________________________________________________________________________________ PLEASE COMPLETE INFORMATION ON REVERSE 3. The third 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:________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Since the last act of violence, explain the delay, if any, in seeking this restraining order: ____________________________________________________________________________________________________ __________________________________________________________________________________ ___________________________________________________________________________________________ The most recent incident of threats to kill me; beat me; take child(ren) was on_____________________. (approx. date) He/She said_________________________________________________________________________________ __________________________________________________________________________________________. Defendant took our child(ren) on ____________________ and will not give them back. (approx. date) Defendant has physically abused/ sexually molested the child(ren). Children's Protective Services is is not involved. Describe the physical abuse: __________________________________________________________________________________________ __________________________________________________________________________________________. Other past incidence of physical abuse:__________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ has; does not have a firearms(s) is registered; Defendant hand-gun; rifle; The firearm(s) is a (mark all applicable): I last saw the firearm(s) on _____________________________. (approx. date) unregistered; do not know. other (describe) ___________________ 4. 5. 6. 7. 8. 9. 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) FL/E-LP-613 (Rev. 1/29/2009) Mandatory Domestic Violence Packet Attachment Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com
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