Superior Court of Washington For Skagit County No.11 2 01122 7 Petition for Order for Prmeclion (PTORPRT) Puliuoncr $ng Ragndem 1 a 11111 11 mum of 1111111511: by me respondent A member ofmy farmly or household is a viclirn of domes": vlalcnce comlrulled by [he respondent. 1:1 1 am aDguardIanU guardian ad lilcm 13112111 friend Ufa mom who is 13 Io 15 years ofag: and 1s a mum of 111111155112 111 a dating mm a person ag: [6 or older The "arm or [he 111111111 mom 15 T1115 person's idenufying 1 fol-manor: 1s 111 Jmmg'aph 5 below. 1 The vrcum 11m 111 1111; county. :1 111: mm 1:11 111:" rcs1dencc because 'of abuse and 1111.: )s 111: county ohhcir or former 3. Th: vrclim's age is: Blinder 16 CI 16111 17 [Borover age 151 DUnder 16 El IE nr 17 Iii/8 Drover 4, Th: mum's "11111111151111; 1111111 111: or former mug 11171111>> 1=1aoo11s111p or child responder" is - 51111111: or far-mar spouse parem or a common child mm" or form, El current or former cohabrram as mumare whabirznl as menu-1312' . panocr, mcludmg currenl or fonncr 0r Stepchild 13 blood rclalion other than 11mm or child Egrsmed domeslrc partner 10H Checked Active Orders Parties? 00w Attached Pezmon for Order for Pmlecllon (PTORPRT) . Page 1 of WPF Mandamry (6/2010) RCW 25. 501030 SCOMIS SEARCH CASE TYPEV 5. Identi?cation of Minors (if applicable?ghlo Minors involved. Name How Related to Resides (First, Middle initial, Last) Age Race Sex Petitioner Respondent with 6. Other court cases or other restraining, protection or tic?contact orders involving me, the minors and the respondent: Case. Name Case Number Cour?County Check the box for each type of relief you are requesting, for each type of order you need. Temp: I Request a Temporary Order for Protection, effective until the hearing, because an Emergency Exists as described in the statement below. A temporary? protection order should be issued immodiately without notice to the respondent, to avoid inoperable injury. Full: I Request a ?full? Order for Protection, following a hearing. Temp Full i i Restrain respondent from causing any physical harm, bodily injury, assault, eluding sexual assault, and from molesting, harassing, threatening, or stalking me the minors named in paragraph 5 above Cl these minors only: (If the court orders this relief, and the respondent is your spouse or former spouse, the parent of a common child, or a current or former cohabitant as intimate partner, including a current or former registered domestic partner, the respondent will be prohibited from possessing a ?rearm or ammunition under federal law 'for the duration of this order. An exception exists for law enforcement of?cers and military personnel when carrying departmentfgovemment-issued ?rearms. 18 U.S.C. 925(a)@ 2 Restrain respondent from harassing, following, keeping under physical or electronic surveillance, cyberstalking as de?ned in RCW 9.61.260, and using telephonic, audiovisual, or other electronic means to monitor the actions, locations, or wire or electronic cemmunication 0M me El the minors named in paragraph 5 above only the minors listed below; Cl members of the victim?s household listed below the victim?s adult children listed below: Petition for Order for Protection - Page 2 of 6 WPF Mandatory {ti/2010) - ROW 26. 50.030 Temp Full . rl Temporary Order, eilective until a hearing. Full Order, effective following a hearing. 3 Restrain respondent from coming near and from having any contact whatsoeverperson or through others, by phone, mail, or any means, directly or indirectly, except for mailing of court documents, witt??me the minors named in paragraph 5 above, subject to any court-ordered visitation El these minors only, subject to any court~ordered visitation: 4 Exclude respondent from El our shared residencri?my residence my workplace [3 my school El the residence, day care, or school the minors named in paragraph 5 above El these minors only: moms? {Parallel Wilcox-3 honW-S You have a tight to keep your residential address con?dential. 5 Direct respondent to vacate our shared residence and restore it to me. 6 Prohibit respondent from knowingly coming within, or loiowingly remaining within (distance) of Cl our shared residencc?my residence my workplace Cl my school the day care or school of El the minors named in paragraph 5 above. El these minors only: El other: 1 Grant me possession of essential personal belongings, including the following: 8 Grant me use of the following vehicle: Year, Make Model License No._ 90then IDDirect the respondent to participate in appropriate treatment or counseling services. . 1' Require the respondent to pay the fees and costs of this action. '2 RamainE?ectr've longer than one year because reSpondent is likely to resume acts of domestic violence against .me if the order expires in a year. Check the following only if you are requesting protection involving pets. '3 Grant the exclusive custody and control of the following pet(s) owned, . possessed, leased, kept, or held by me, respondent, or a minor child residing with either me or the respondent. (Specify name of pet and type of animal): Petition for Order for Protection (PTORPRU Page 3 of 6 WPF Div-1.015 Mandatory (6/2010) - RCW26.50.030 2.3-3: '4 Prohibit respondent from interfering with my efforts to remove the pet(s) named above. [1 15? Prohibit TESp-Ondenl from knowingly coming within, or knowingly remaining within (distance) of the following locations where the pet(s) are regularly found: petitioner?s residence (You have a right to keep your residential address con?dential.) [3 Park El other: Check the following only if you are requesting protection involving a minor; fj El 1" Subject to any court-ordered visitation Grant me the care, custody and control of Cl the minors named 111 paragraph 5 above these minors only: E) 17 Restrain respondent from interfering with my physical or legal custody of Cl the minors named in paragraph 5 above El these minors only: ?3 Restrain the respondent from removing from the state: I: the minors named in paragraph 5 above Cl these minors only: Request for Special Assistance From Law Enforcement Agencies: 1 request the court order the appropriate law enforcement agency to assist me in obtaining: Possession of my residence. L__l Possession of the vehicle designated above. Possession of my essential personal belongings at the shared residence El respondent?s residence El other location El Custody of the minors named in paragraph 5 above these minors only (if applicabie): El Other: "Domestic violence? means physical harm, bodily injury, assault, including seitual assault, stalking, in?icting fear of imminent physical harm, bodily injury or assault between family or household members. Statement: The reSpondent has committed acts of domestic violence as follows. (Describe swi?c acts of domestic violence and their approximate dates, beginning with the most recent act. You may want to include police reaponses Describe the most recent incident or threat of violence and 0'1: 0 min1-9 ?an. n? a I no.3? I. toPetition for Order for Protection (PTORPRT) - Page 4 of 6 WPF Div-1.075 Mandatory (6/2010) - RCW 26.50.030 i .I- u- thrust altau. A a. t. term. I- x..L'in! unit Til 23:2,) Describe the past incidents where you experienced violence. where you were afrai of injury or where i the threatened to harm or kill you: I Describe any violence or threats towards children: Describe any stalking behavior by respondeni including: use of telephomc audiovisual or electr - means to harass or monitorinmmumun uLoe 0 [?1ng JANA Mmr?fs Describe medical treatmeni you received and for Petition for Order for Protection (PTORPRT) - Page 5 of 6 WPF Mandatory (6/2010) - RCW 215-50.an l) Descnbe any lhrcals ofsuiclde or sulcudal hehavmr by Ike KIM m. was Does {11: own or possess firearms? DYes a Does the rcspundem use firean'ns. weapons or objecls Io llutalcn or harm yam? Please describe, (Column: on swam: pagc Mugs" Check hox .r subsume abuse is involved: El alcohol CI other El Personal semce cannot be made upon respondcul wllhin the slate of Iccnify undcr penally under the laws othe slate of Washuagton the! lhe foregmng is Iruc and correct, Dated. 315432 20" at Washm on Signalure or Pctitioncr You have 2 nglu \o knep your Icsidenual address confidential. lf you hm other than iuur isidtnc: where ion msi lecciv: lciil di mulls Petition for Order for Pmlecll'an (PTORPRT) - Page 6 (fl 6 WPF DV71 015 Mandala/y (6/2010) - RCW 26 501130