Free Elder Abuse Restraining Order Incident Summary (FL/E-LP-614) - California

FL/E-LP-614

Attachment to Application For PETITION FOR PROTECTIVE ORDERS (Elder or Dependent Adult Abuse)

Allegations of Abuse 1.

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 Was a report taken? Yes No Report number: _________________________ Other injuries: _____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

2.

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

Page 1 of 2 FL/E-LP-614 (Rev. 1/29/2009) Mandatory Elder Abuse Packet Attachment www.saccourt.ca.gov

FL/E-LP-614

3.

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:_____________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

4.

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 was on_________________. (approx. date) He/She said___________________________________________________________________________ _____________________________________________________________________________________.

5.

6.

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

7.

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)

Page 2 of 2 FL/E-LP-614 (Rev. 1/29/2009) Mandatory Elder Abuse Packet Attachment www.saccourt.ca.gov