Request for Domestic Violence Restraining Order You must also complete Form CLETS-001, Confidential CLETS Information, and give it to the clerk when you file this Request. ‘ler stamps date here when form is ed FILED Superior Court of California ‘County of Los Angeles Ni Pe Asking for Protection: © Npng ee Petpon eke er re eT age SEP 08 2021 Your lawyer in this ease (ifyou have ane): Bea Ok NE igen] Sherri. Cazteyginccun ‘Name: State Bar No.: By. Firm Name af Brome Address (if you have a lawyer for this case, give your lawyer's Flin court ama and are oe information. If you do not have a lawyer and want to keep your home address private, give a different mailing address instead. You do not have Superior, Cou? of Oaltornie: Gouney ott Los Angeles Superior Court 10 give your ple Address (\ City: 4b Telephone: Fax: E-Mail Address: Nai rson You Want Protection From: Description of person yu want protection from: Santa Monica Courthouse 1725 Main Street, Rm 225 Santa Monica, CA 90401 Court ils in ease number wien frm i led Case Number: ss ‘Sex: ty OE_ Height: (p 4 Weight: 230 — HairCotor [A ye Cplor Py Race: Date of Birth: Address gino ry ae 4b ming City: “Mae State hk a Do you want an order to protect family or household memi yes ist them: Lives with you? bers? “Mve No Relationship to you ondn Ce ae "Kuen jo ve TiN Bhatt D Yes O No O Yes G No Cl Check here ifyou need more space. Attach a sheet of paper and write “DV-100, Protected People” for a ttl. What is your relationship to the person in(@) ? (Check all shat apply). a. O Weare now married or registered domestic partners, TFyon do nat area on of have volalonstipa, b. C] We used to be married or registered domestic partners. ‘he court may not be able to consider your c. [] We live together. request. Read Form DV-500-INFO for help. 4. O] We used to live together, ©. We are related by blood, marriage, or adoption (specify relationship): fC] Weare dating or used to date, or we are or used to be engaged to be marti 8 C] Weare the parents together of a child or children under 18: Child's Name: _____ Date of Birth: _ Child's Name: Date of Birth: 2 Child’s Name: Date of Birth: O Check here if you need more space. Aitach a sheet of paper and write “DV-100, Additional Children” for @ title h. C1 We have signed a Voluntary Declaration of Paternity for our child or children. (Attach a copy if you have one). ‘vse ami Cate, a0 toe (DV-100, Page 1 of6 Request for Domestic Violence Restraining Order ae (Domestic Violence Prevention)(Case Number: : | 21SHROO0166 ©) Other Restraining Orders and Court Cases a. Are there any restraining/protective orders currently in place OR that have expired in the last six months (emergency protective ores eral, jy, fay)? ONo. B Yes (dee of order)h PV [ML and exprain date)4 [3] 2). catach a cony you have one) sip oe ayer ern ame in) en inva naar cn wih i pean mG? No. BL Yes I/yes, check each kind of case and indicate where and when each was filed: Kind of Case County or Tribe Where Filed Year Filed Case Number (iffnown D Divorce, Nullity, Legal Separation CQ Civil Harassment Criminal Juvenile, Dependency, Guardianship © Child Support i Parentage, Paternity © Other (specify): a i Check here ifyoirneed mare space. Aitach a sheet of paper and write tile. Check the orders you want. (i Personal Conduct Orders Task the court to order the person in (2) not to do the following things to me or anyone listed in@) a. OL Haras, attack, strike, threaten, assault (sexually or otherwise, ht follow, stalk, molest, destroy personal property, disturb the peace, keep under surveillance, impersonate (on the internet, electronically or ctherwise), of block movements b. (PL Contact, either directly or in or other electronic means: The person n@ will be ordered not to take any action to get the addresses or locations of any protected person unless te court finds good cause not fo make the order. Q Stay-Away Order 2 [ask the court to order the person in @to stay at east [UO yards away from (check all that apply) Me My schoo! My home: one person listed in @) “T00, Other Court Cases” for a ctly, in any way, including but not limited to, by telephone, mail or e-mail My job or workplace The child(ren)’s school or child care My vehicle Other (specif) if b. Ifthe person listed in (@) is ordered to stay away from all the places listed above, will he or she still be able to ‘get to his or her home, school, job, workplace, or vehicle? W@W Yes () No (ifno, explain). (®) D Move-Out Order (the person in (2) lives with you and you want that person to stay away from your home, you must ask for this move-out order.) Task the court to order the person in (2) to move out from and not return to (address) have the right to live at the above address because (explain): EE aie Request for Domestic Violence Restraining Order DV-100, Page 2 of 6 (Domestic Violence Prevention) >‘Case Number } 21SHRO00166 Guns or Other Firearms or Ammunition I believe the person in @) owns or possesses guns, firearms, or ammunition. [] Yes [] No (if Idon’t know Ifthe judge approves the order, the person in (2) wll be ordered nao own, paasess purchase, or revelve a firearm or ammunition. The person will be ordered to sellto, or store with, a licensed gun dealer, or turn in to law enforcement, any guns or firearms that he or she owns or possesses. Record Unlawful Communications Task for the right to record communications made to me by the person in @) that violate the judge's orders. ) Bl Care of Animals 1 ask forthe sole possession, care, and control ofthe animals listed below. I ask the court to order the person in @ tostay atleast] [()__ yards away from and not take, sell, transfer, encumber, conceal, molest, attack, itike, threaten, harm,'or otherwise dispose of the following animals: i ait $ nts Out ha, eee [ask for the animals to be with me because: (2) 0 Child Custody and Vi a C) Ido not have a child custody or visitation order and I want one. 'b. C] Ihave a child custody or visitation order and I want it changed. Ifyou ask for orders, you must fill out and attach Form DV-103, Request for Child Custody and Visitation Orders. Youand the other parent may tell the court that you want to be legal parents of the children (use Form DV-180, ‘Agreement and Judgment of Parentage). @® CO Child Support (Check ail that apply): a. CO) Ido not have a child support order and | want one. b. C1 Ihave a child support order and I want it changed, c. C] Inow receive or have applied for TANF, Welfare, Cal WORKS, or Medi-Cal Ifyou ask for child support orders, you must fll out and attach form F150, Income and Expense Declaration or Form FL-155, Financial Statement (Simplified) (14) Cl Property Control 1 ask the court to give only me temporary use, possession, and control of the property listed here: C Debt Payment Task the court to order the person in (@)to make these payments while the order is in effect i Check here if you need more space. Attach a sheet of paper and write “DY-100, Debt Payment for a ttle. Pay to: For: Amount: $ Due date: (CO Property Restraint Lam married to or have a registered domestic partnership with the person in (2) . I ask the judge to order that the person in @) not borrow against, sell, hide, or get rid of or destroy any possessions or property, except in the usual course of business or for necessities of life. | also ask the judge to order the person in (2) to notify me of any new or big expenses and to explain them to the cour. @) Ci Spousal Support Tam married to or have a registered domestic partnership with the person in @) and no spousal support order exists. I ask the court to order the person in (2) to pay spousal support. (You must complete, file, and serve FL-150, Income and Expense Declaration, before your hearing). Thi not a Court Or roms a Request for Domestic Violence Restraining Order V-100, Page of 8 (Domestic Violence Prevention) >liaeunseurnnnicel Tambor (i Rights to Mobile Device and Wireless Phone Account a. C1] Property control of mobile device and wireless phone account Task the court to give only me temporary use, possession, and control of the following mobile devices: and the wireless phone account for the Tollowing wireless phone numbers because the account currently belongs to the person in (2) (including area code): T] my number [} number of child in my care (including area code): CH my number) number of child in my care (including area code) i my number) number of child in my care Oi Check here if you need more space. Attach a sheet of paper and write “DV-100, Rights to Mobile Device and Wireless Phone Account" for a tite. b. O) Debt Payment Trask the court to order the person in (2) to make the payments for the wireless phone accounts listed in 18a because: [Name of the wireless service provider i= Amount Iyou are requesting this order, you musi complete, file, and serve E Declaration, before your hearing. c. CJ Transfer of Wireless Phone Account Task the court to order the wireless service provider to transfer the billing responsibility and rights to the wireless phone numbers listed in 18a to me because the account currently belongs to the person in (2) Ifthe judge makes this order, you will be financially responsible for these accounts, including monthly service {fees and costs of any mobile devices connected to these phone numbers. You may be responsible for other fees. You must contact the wireless service provider to find out what fees you will be responsible for and whether you are eligible for an account. i) O Insurance ask the court to order the person in (2) NOT to cash, borrow against, cancel, transfer, dispose of, or change the beneficiaries of any insurance or coverage held for the benefit of me or the person in (2), or our child(ren), for whom support may be ordered, or both @®) D Lawyer's Fees and Costs ask that the person in (@) pay some or all of my lawyer's fees and costs. You must complete, fil, and serve form FL-150, Income and Expense Declaration, before your hearing. @) 0 Payments for Costs and Services Task the court to order the person in (2) to pay the following: You can ask for lost earnings or your casts for services caused directly by the person in (2) (damaged property, medical care, counseling, temporary housing, etc, You must bring proof of these expenses to your hearing. Pay to: For ___ Amount: $ Due Date: =130, Ticome and Expense Pay to: For: Amount: $ @® © Batterer Intervention Program I ask the court to order the person listed in (2) to go to a $2-week batterer intervention program and show proof cof completion to the court @8) C1 Other Orders What other orders are you asking for? CO Check here ifyou need more space. Attach a sheet of paper and write “DV-100, Other Orders” for a tite i ror Serer Request for Domestic Violence Restraining Order ~DVA00, Pages oe (Domestic Violence Prevention) > porns(Case Number: 21SMROO0166 e for Service (Notice) The papers must be personally served on the person in (2) at least five days before the hearing, unless the court orders a shorter time for service. Ifyou want there to be fewer than five days between service and the hearing, explain why below. For help, read Form DV-200-INFO, “What ls Proof of Personal Service”? ae (@) No Fee to Serve (Notify) Restrained Person Ifyou want the sheriff or marshal to serve (notify) the restrained person about the orders for free, ask the court clerk what you need to do. Court Hearing ‘The court will schedule a hearing on your request. Ifthe judge does not make the orders effective right away (temporary restraining orders”), the judge may still make the orders after the hearing, If the judge does not make the orders effective right away, you can ask the court to cancel the hearing, Read fd Waiver of Hearing on Denied Request for Temporary Restraining Order, for more information. @) Describe Abuse Describe how the person in(@) abused you. Abuse means to intentionally or recklessly cause or attempt to cause bodily injury to you; or to place you or another person in reasonable fear of imminent serious bodily injury; or to harass, attack, sirike, threaten, assault (sexually or otherwise), hit, follow, stalk, molest, Keep you under surveillance, impersonate (on the Internet, electronically or otherwise), batter, telephone, or contact you; or to disturb your peace; or to destroy your personal property. (For a complete definition, see Fam. Code, §§ 6203, 6320.) " 3 a Date of most recent abuse 1. Who was there? M1 2. Dpseribe y Cl Check here if you need more space. Attach a sheet of paper and write “DV-100, Recent Abuse” for a ttle. 3. Did the person in 2) use o threaten to use agun or any other weapon? ff} No C) Yes Wfyes, describe) 4, Describe any injuries: 5. Did the police come? GJ No [] Yes If yes, did they give you or the person in(2) an Emergency Protective Order? [] Yes [J No C1 I don’t know Attach a copy if you have one The order protects [] you or [1] the person in @) This is not a Court Orde Request for Domestic Violence Restraining Order DV-100, Page sors (Domestic Violence Prevention) —_Case Number 2ISMROGO3 GO Describe Abuse (continued) Has the person in (2) abused you (or your child(ren)) other times? 1 Check here ifyou need more space. Attach a sheet of paper and write “DV-100, Recent Abuse” for a tite. jd the person in(2) use or threaten to use a gun or any other weapon? a No (] Yes (ifyes, describe). juries: _ VID fils we a a 5. Did the police come? No O] Yes Ityes, did they give you'or the person in @) an Emergency Protective Order? Gi Yes C] No [1] Idon'tknow Attach a copy ifyou have one. The order protects [] you or the person in @) Ifthe person in @) abused you other times, check here {]and use Form D¥-101, Description of Abuse or describe any previous abuse on an attached sheet of paper and write “DV-100, Previous Abuse” for a title. Other Persons to Be Protected ‘The persons listed in item (@) need an order for protection because (describe): 4, Describe any nia that the information above is true and correct. I declare under penalty of perjury under the laws of the State of Cali Wun Sighs name, imine kone Tovnd ar Oe 1g Order DVD, Paseo ore [Bedsy sal Type or print your name pa: 4 1 [atx , Request for Domestic Violence Restraii 400, cu edn At lagen Train maa Danes te valeren test01 ‘This form is attached to DV-100, Request ad Domestic Violence Restraining Order Description of Abuse cose Mn SHROOO166 GQ) Name of person asking for protection: Dale, (Q) Name of person you want protection from: ab Hum sant Describe abuse to you or your children, 4. Deseribe 2 FY use oF threatened use of guns or other weapons: hay Describe any injuries: _ fly le f. Did the police or other law enforcement come? 2) No [) Yes Ites, did they give you or the person in@) an ‘The Emergency Protective Order protects [] You [] The person in @) Attach a copy of the Emergency Protective Order if you have one. smergency Protective Order?) Yes [] No [J I don’t know Description of Abu: (Domestic Violence Prevention) DV-101, Page 1 of2 >ase Number: 21SHROOE1EE (4) Describe abuse to you or your children, Has the person in (2) abused you (or your children) other times? 4. Describe any uge or threatened use of guns or ther weapons: Ee fe. Describe any injuries: Phy ad f. Did the police or other law enforcement come? Gf] No 1] Yes Ityes, did they give you or the person in 2) an Emergency Protective Order?(] Yes [) No [] I don't know ‘The Emergency Protective Order protects [] You [] The person in @) Attach a copy of the Emergency Protective Order if you have one. ©) Desgrive abuse to you or your children Val OO Check here if you need more space. Attach a sheet of paper and write “DY-101—Description of Abuse” for a title. ev ionan 17 Description of Abuse DV-101, Page 2 0f2 (Domestic Violence Prevention)