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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

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

The most recent incident of threats to ¨ kill me; ¨ beat me; was on_____________________. (approx. date) He/She said_________________________________________________________________________________ ____________________________________________________________________________________ ______. 5. 8. Other past incidence of physical abuse:__________________________________________________________ ____________________________________________________________________________________ ______ ____________________________________________________________________________________ ______ ____________________________________________________________________________________

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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)

Revised 12//00

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