Free Domestic Violence Restraining Order Incident Summary (FL/E-LP-613) - California

FL/E-LP-613

Domestic Violence Packet Attachment to Application For DOMESTIC VIOLENCE RESTRAINING ORDERS 1. Have you participated in another case against the person who is to be restrained which involves child custody and/or visitation? Yes No Name of Court and case number: __________________________________________________________. The Court's order or judgment regarding child custody and/or visitation was: ________________________ ____________________________________________________________________________________. The child (ren) have been living with Mother Father Partner, since ________________________. (approx. date) Are you currently involved in a dependency case? ____ Yes ____No I have 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:_______________________________________________________ I have had no previous restraining orders against the person who is to be restrained. The most recent incident of abuse by the Defendant was ________________________________. (approx. date) Defendant: hit me on the: arms legs face head stomach back 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 my hair strangled me left bruises; describe: _______________________________________________________. sexually abused me, describe: ________________________________________________. City Police/Sheriff was called; Defendant was arrested Report number: _________________________ Was a report taken? Yes No Other injuries: _____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ The second most recent incident of abuse by the Defendant was ____________________________. (approx. date) Defendant: hit me on the: arms legs face head stomach back 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 my hair strangled me left bruises; describe: _______________________________________________________. sexually abused me, describe: ________________________________________________. City Police/Sheriff was called; Defendant was arrested Was a report taken? Yes No Report number: _________________________ Other injuries:_____________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ PLEASE COMPLETE INFORMATION ON REVERSE

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FL/E-LP-613 (Rev. 3/26/2009) Mandatory

Domestic Violence Packet Attachment

Page 1 of 2 www.saccourt.ca.gov

FL/E-LP-613

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The third most recent incident of abuse by the Defendant was

___________________________. (approx. date) Defendant: hit me on the: arms legs face head stomach back 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 my hair strangled me left bruises; describe: _______________________________________________________. sexually abused me, describe: ________________________________________________. City Police/Sheriff was called; Defendant was arrested Was a report taken? Yes No Report number: _________________________ Other injuries:_____________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

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Since the last act of abuse, 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 abuse: _____________________________________________________________________________________ _____________________________________________________________________________________. Other past incidence of abuse:__________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ has; does not have a firearms(s) which is registered; unregistered; do not know. Defendant hand-gun; rifle; other (describe) ___________________ The firearm(s) is a (mark all applicable): I last saw the firearm(s) on _____________________________. (approx. date)

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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. 3/26/2009) Mandatory

Domestic Violence Packet Attachment

Page 2 of 2 www.saccourt.ca.gov