General Civil and Domestic Relations Case Filing Information Form

o Superior or 0 State Court of __--______ County

Plaintiff(s Defendant(s

Last First Middle I Suffix Prefix last First MiddleL Suffix Prefix

last First Middle 1 Suffix Prefix last First MiddleL Suffix Prefix

last First Middle I Suffix Prefix last First Middle I Suffilc Prefix

last First Middle I Suffix Prefix last First Middle I SuffIX Prefix

Plaintiffs Attorney _____________ Bar Number Self-Represented 0

Check One Case Type in One Box

General Civil Cases

0 Automobile Tort 0 Civil Appeal 0 Contract 0 Garnishment 0 General Tort 0 Habeas Corpus 0 InjunctionMandamusOther Writ 0 landlordlTenant 0 Medical Malpractice Tort 0 Product Uability Tort 0 Real Property 0 Restraining Petition 0 Other General Chil

Domestic Relations Cases

0 Adoption 0 DissolutionDivorceSeparate

Maintenance 0 Family Violence Petition 0 Paternityleg itimation 0 Support -lV-D 0 Support - Private (non-IV-D) 0 Other Domestic Relations

Post-Judgment - Check One Case Type

0 Contempt 0 Non-payment of child support

medical support or alimony 0 Modification 0 OtherAdministrative

o Check if the action is related to another action(s) pending or previously pending in this court involving some or all of the same parties subject matter or factual issues If so provide a case number for each

Case Number Case Number

o I hereby certify that the documents in this filing including attachments and exhibits satisfy the requirements for redaction of personal or confidential information in OeGA sect 9-11-71

o Is an interpreter needed in this case If so provide the language(s) required __________ Language(s) Required

o Do you or your client need any disability accommodations If so please describe the accommodation request

Version 1118

THE SUPERIOR COURT FOR THE COUNTY OF Floyd-------shy

STATE OF GEORGIA

] Petitioner ] Civil Action File

] v ] No _____

] ]

Respondent ]

PETITION FOR TEMPORARY PROTECTIVE ORDER

The Petitioner pursuant to the Family Violence Act at OCGA I 19-13-1 et~ files this Petition for a Family Violence Protective Order and in support shows the ltourt the following

J bull The Petitioner is a resident of County Georgia and is 18 years of age or older or is an emancipated minor Petitioner=s year of birth is ________ sex __ race ___

2 The Respondent is a resident of ________ County Georgia and may be served _____ Georgia Jurisdiction and venue are proper witb this Court

OR 2a Respondent is a resident ofthe State of Under OCGA 19shy

] 3-2(b) jurisdiction and venue are proper witb this Court because the abuse occurred in the State of Georgia in County andor the Petitioner lives in _______ County Respondent is subject to the jurisdiction of this Court and may be served

3 Petitioner and Respondent are o I Present or past spouses ~ 2 Parents of the same childrenD 3 Parent and childreno 4 Persons who used to live in the same household D 5 Persons currently living in the same householdD 6 Foster parent and foster child [J 7 Stepparent and stepchild

4 On or about __ the Respondent committed the following acts of familyviolence against the Petitionerandor minor childlen __ ______

I

middot i

------------~-----------------~----------------------

Petitioner is in reasonable fear for Petitioner=s own safety andor the safety of the minor childreno

5 At other times the Respondent has committed other such acts including but not limited to (approximate dates and what happened)

6 There is a substantial likelihood that the Respondent will commit such acts of violence against the Petitioner and minor children in the immed iate future if reI ief is not granted as provided pursuant to OCOA J9-13-4I

Check the paragraphs below that apply to your case FilJ in the information needed by each paragraph you check

o 7 Petitioner and Respondent have ___ children under the age of 18 Their names year of birth sex and ages are _______________________________

These children have lived only with Petitioner and Respondent for the past five (5) years (If-thechildlren have notresidedon 1~lwiththeJ~etitioner-and Respondentior _ _ the last five years give names of the persons their addresses and dates the children resided with

2

THE SUPERIOR COURT FOR THE COUNTY OF Floyd-------shy

STATE OF GEORGIA

] Petitioner ] Civil Action File

] v ] No _____

] ]

Respondent ]

PETITION FOR TEMPORARY PROTECTIVE ORDER

The Petitioner pursuant to the Family Violence Act at OCGA I 19-13-1 et~ files this Petition for a Family Violence Protective Order and in support shows the ltourt the following

J bull The Petitioner is a resident of County Georgia and is 18 years of age or older or is an emancipated minor Petitioner=s year of birth is ________ sex __ race ___

2 The Respondent is a resident of ________ County Georgia and may be served _____ Georgia Jurisdiction and venue are proper witb this Court

OR 2a Respondent is a resident ofthe State of Under OCGA 19shy

] 3-2(b) jurisdiction and venue are proper witb this Court because the abuse occurred in the State of Georgia in County andor the Petitioner lives in _______ County Respondent is subject to the jurisdiction of this Court and may be served

3 Petitioner and Respondent are o I Present or past spouses ~ 2 Parents of the same childrenD 3 Parent and childreno 4 Persons who used to live in the same household D 5 Persons currently living in the same householdD 6 Foster parent and foster child [J 7 Stepparent and stepchild

4 On or about __ the Respondent committed the following acts of familyviolence against the Petitionerandor minor childlen __ ______

I

middot i

------------~-----------------~----------------------

Petitioner is in reasonable fear for Petitioner=s own safety andor the safety of the minor childreno

5 At other times the Respondent has committed other such acts including but not limited to (approximate dates and what happened)

6 There is a substantial likelihood that the Respondent will commit such acts of violence against the Petitioner and minor children in the immed iate future if reI ief is not granted as provided pursuant to OCOA J9-13-4I

Check the paragraphs below that apply to your case FilJ in the information needed by each paragraph you check

o 7 Petitioner and Respondent have ___ children under the age of 18 Their names year of birth sex and ages are _______________________________

These children have lived only with Petitioner and Respondent for the past five (5) years (If-thechildlren have notresidedon 1~lwiththeJ~etitioner-and Respondentior _ _ the last five years give names of the persons their addresses and dates the children resided with

2

middot i

------------~-----------------~----------------------

Petitioner is in reasonable fear for Petitioner=s own safety andor the safety of the minor childreno

5 At other times the Respondent has committed other such acts including but not limited to (approximate dates and what happened)

6 There is a substantial likelihood that the Respondent will commit such acts of violence against the Petitioner and minor children in the immed iate future if reI ief is not granted as provided pursuant to OCOA J9-13-4I

Check the paragraphs below that apply to your case FilJ in the information needed by each paragraph you check

o 7 Petitioner and Respondent have ___ children under the age of 18 Their names year of birth sex and ages are _______________________________

These children have lived only with Petitioner and Respondent for the past five (5) years (If-thechildlren have notresidedon 1~lwiththeJ~etitioner-and Respondentior _ _ the last five years give names of the persons their addresses and dates the children resided with

2

D 8 The parties are not married and the Respondent _____ (has OR bas not) legitimated the children of the parties

D 9 Petitioner (does OR does not) have knowledge concerning cllstody or claims of custody concerning these children including divorce separation juvenile and DFCS cases Specify court and type of caseOf applicable)

o 10 Petitioner has the following minor children living with Petitioner whom the Petitioner wishes protected from the Respondent and included in the Protective Order (names and ages)__________________________

Q II Petitioner believes Respondent has a criminal record and has committed the following crimes (approximate dates and crimes) ____________

o 12 Petitioner fears that if Respondent learns of Petitioner=s current address that Respondent will hurt or injure Petitioner or Petitioner=s immediate family Petitioner requests that Respondent not be informed of Petitioner=s current residence

o 13 Petitioner is dependent lIpon the family residence for shelter for the Petitioner andor minor children and asks that Petitioner be granted the temporary lise and possession ofsaid residence located at together with all personal property contained therein with the exception of Respondent=s personal clothing

o 14 Petitioner and minor children are dependent upon the Respondent for support and requests that Petitioner be awarded temporary child suppo11

D 15 Petitioner is dependent lipan the Respondent for support and asks that Petitioner be awarded temporary support

o 16 The minor children are currently in the clistody and control of the -PetitionerRespondent and-Petitioner- asls-legalandphysicalclIstody

o 17 Petitioner asks that the following assetsplOperty ofthe Petitioner be returned by the

3

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Respondent _____________________~___

THEREFORE Petitioner asks

(a) That the Court set a hearing no later than thirty (30) days fi-om the filing of the Petition and direct Respondent to appear before this Court and show any reasons why the demands of the Petitioner should 110t be granted

(b) That the Respondent be served a copy ofthis Petition and Ex Palte Protective Order as required by law

(c) That this Court direct law enforcement to enforce this Order

(d) That this Court direct Respondent to stop abusing harassing and intimidating Petitioner andor Petitioner=s children

(e) That this Court restrain and enjoin Respondent from having any direct or indirect contact with the Petitioner andor Petitioners children

(f) That this Court order that Respondent be enjoined from approaching within __ yards of Petitioner

(g) That this Court make findings offact and conclusions of law concerning the issues in this case

(h) That Petitioner have such other and further relief as the COLlli may deem just and proper

(i) That this Court issue Family Violence Ex Parte and Twelve Month Protective Orders to

Check the following paragraphs that apply to your case Fill ill the information needed by each paragraph you check

o award Petitioner temporary sole legal and physical custody of the minor children

o order Respondent to vacate the family residence at - - - --instanter

C grant Petitioner exclusive temporary LIse and possession oftile family residence at __

4

_______________and alJ personal property ofthe palties located at the family residence and Petitioner=s current residence with the exception ofRespondent=s personal clothing that law enforcement (sheriff or police department) assist Petitioner in returning to the family residence and in ensuring that the Respondent vacates said residence and that all keys garage door openers and other security devices to the family residence are secured and given to the Petitioner

o order Respondent to provide suitable alternate housing for Petitioner andor Petitioner=s children

o order Respondent to stay away fiom Petitioner=s and 01 Petitioner=s minor children=s place of residence place of employment andor school

o order Respondent=s visitation with the minor children be limited to no visitation or

D order Respondent to pay to Petitioner child support for the minor children

o order Respondent to pay spousal support for Petitioner

I I award the Petitioner costs and attorney=s fees for having to bring this action

D order that Petitioner=s current address be kept confidential

Dmiddot enjoin and restrain Respondent from selling disposing or encumbering trading contracting to sell or otherwise disposing or removing from the jurisdiction of this Court any of the property ofPetitioner or of the parties except in the ordinary course of business

o enjoin and restrain Respondent from disconnecting the home utilities changing andor canceling auto health or life insurance for Respondent Petitioner andor the Petitioner=s minor children andor interfering with Petitioner=s or the Petitioner=s minor children=s mail

o grant Petitioner the use of the following automobile Make Model Year__ and law enforcement (sheriff or police department) ensure that all keys to said vehicle be immediately returned to Petitioner

o permit Petitioner to remove the following property from the residence for the exclusive use by Petitioner andor the minor chiJdren _

and law enforcement~_____(sheriff or police depal1ment) be ordered to assist the Petitioner during this removal

5

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THE SUPERIOR COURT FOR THE COUNTY OF ____F_L_O_Y_D___

STATE OF GEORGIA

J Petitioner J Civil Action File

J J No ____________________

] J

Respondent ]

VERIFICATION

Personally appeared who being duly sworn states that shehe is the Petitioner in the above styled case and that the facts set forth in the foregoing Petition for Temporary Protective Order are true and correct

Petitioner

Address ----~-----------------

City State _____________________

Phone (Do not give current address if confidential give alternative address)

Sworn and subscribed before me this ___ day of__________________

NOTARY PUBLIC My commission expires

OR] Number _0_5_7____

THE SUPERIOR COURT FOR THE COUNTY OF Floyd------shy

STATE OF GEORGIA

Petitioner Civil Action File v

Respondent

FAMlL Y VIOLENCE EX PARTE PROTECTIVE ORDER

The Petitioner having prayed pursuant to OCGA sectsect 19-13-1 et gm that a Protective Order be issued and alleged that Respondent has committed acts of Family Violence and that Petitioner is in reasonable fear of the Petitioners safety and the safety of Petitioners children and it appearing to the Court that probable cause exists that family violence has occurred in the past and may occur in the future IT IS HEREBY ORDERED AND ADJUDGED

1 That these proceedings be filed in the office of the Clerk of this COUlt

2 That this Order applies in every county throughout the state and it shall be the duty ofevery court and every law enforcement official to enforce and carry out the provisions ofthis Order pursuant to OeGA sect 19-134(d) Law Enforcement officers may use their arrest powers pursuant to 0 CGA sectsect 19-13-6 and 174-20 to enforce the tetms of this Order

3 That a copy of this Order be given to law enforcement and the Respondent be served with a copy of this Order and Petition for Temporary Protective Order instanter

4 iThat the Respondent appear before this Court on the _ day of

i---- ____ 20__ at m in room of the 1_______ County Courthouse at ____________

to show cause why the requests of the Petitioner should not be granted

CIVIL ACTION FILE NO ______

5 That Respondent is hereby enjoined and restrained from doing or attempting [peoOI) to do or threatening to do any act of injury maltreating molesting following harassing

hanning or abusing the Petitioner andor the minor children in any manner Respondent is not to intelfere with Petitioners travel transportation or communication Respondent shall not follow place under surveillance or contact the Petitioner at any place of the Petitioner for the purpose of harassing and intimidating the Petitioner

6 That the Respondent is enjoined and restrained from doing or threatening to do [peo02) any act of injury maltreating molesting harassing hanning or abusing the Petitioners

fumily or household

7 That this Court determined that it had jurisdiction over the parties and the subject matter under the laws of the State of Georgia and the Court ordered that the Respondent be given reasonable notice and opportunity to be heard sufficient to protect the Respondents due process rights This Order shall be presumed valid and pursuant to 18 USC sect 2265(a) shall be accorded fuJI faith and credit by any other state or local jurisdiction and shall be enforced as if an Order of the enforcing state or jurisdiction

ONLY THE FOLLOWING THAT ARE INITIALED BY THE JUDGE SHALL APPLY

8 That until further Order by this Court Petitioner is awarded sole and exclusive use [peo03) ofthe family residence at _____________~______

9 Respondent is ordered to leave the family residence immediately and law enforcement _______ (sheriff or police department) is ordered to assist Petitioner in returning to the family residence and the removal of tile Respondent Respondent is to immediately surrender to law enforcement (sheriff or police department) all and any keys garage door openers and other security devices to the fami ly residence and law enforcement is to insure that these are given to the Petitioner

10 Respondent is ordered to provide suitable alternate housing for Petitioner andor Petitioners children by _____________

11 Petitioners address is ordered to be kept confidential

2

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middot

12 [pen04]

13

[peoOl04]

14 [peoOS]

15 [peo09]

[peo06]

16

17

CIVIL ACTION FILE NO _____

Respondent is ordered to stay away from Petitioners and Petitioners minor childrens residence at and workplace at or school and any subsequent residence or workplace or school of Petitioner andlor Petitioners minor children

That until further Order of this Court Respondent is restrained and enjoined fiom

approaching within ___ yards of Petitioner andor Petitioners minor children

Respondent is ordered not to have any contact direct indirect or through another person with Petitioner by telephone pager fax e-mail or any other means of communication except as specified in this Order

That Petitioner is awarded tempora)1 cListody of the minor children namely yaB sex yaB sex yaB ______ sex ___ yaB ________ sex ___

Respondent is ordered not to interfere with the physical custody of the childreno

Check here only ifRespondent is awarded temporary cListody of childreno

That Respondent is ordered to pay temporary child support for the minor childlren to Petitioner in the amount of every beginning ____ All payments shall be made by or to __ income deduction order

__ child support receiver __ by mail directly to the Petitioner

or

That Respondent is ordered to pay temporary support for the Petitioner in the amount of $ every beginning ___________ All payments shall be made by or to __ income deduction order

__ child SUppOIt receiver by mail directly to the Petitioner

or

3

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CIVIL ACTION FILE NO _____

18 That Respondent only when accompanied by local law enforcement shall be able to remove hislher clothing and personal items from the residence as follows

On _____________20__ at ____ m

J 9 That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to sell encumber trade damage contract to sell 01

otherwise dispose of or remove fiom the jurisdiction of this Court any of the property or pets of the Petitioner or joint property or pets of the parties except in the ordinary course of business

20 That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to disconnect or have disconnected the home utilities change or have changed andor cancel or have canceled auto health or life insurance for Respondent Petitioner andor Petitioners children or interfere with Respondent Petitioners andor Petitioners childrensmail

21 That Petitioner is awarded temporary sole possession ofthe vehic1e Make Model Year Color Respondent shall immediately sunender all keys proof of insurance and registration to this vehicle to law enforcement and law enforcement shall immediately turn over said items to Petitioner

22 That Petitioner shall be allowed to remove the following property fiom the family residence for Petitioner andor Petitioners childrens use

On 20__ at and law enforcement (sheriff or police department) is hereby ordered to assist the Petitioner during this removal

23 That Respondent shall be required to rerum the following property for Petitioner andor Petitioners childrens use

________________________ On

_____________ 20__ at and law enforcement ________________ (sheriff or police depaltment) is hereby ordered to

-- - - --lt- -- --assisrthe-Petitionerwith this rerum - - ---- shy

4

CIVIL ACTION FILE NO ~____

24 1t is further Ordered

[pooOS]

SO ORDERED this __ day 20 --~-----

JUDGE SUPERIOR COURT _Floyd County

Print or stamp Judges name

Violation of the above Order may be punishable by arrest

5

CIVIL ACTION F1LE NO __

NOTICE TO RESPONDENT 1 Violation of this Order may result ill immediate arrest and criminal prosecution that may

result in jail time andor fines andlor may subject you to prosecution and penalties for contempt of court

2 This Ordershall remain in effect unless specifically superceded by a subsequent signed and filed Order by operation of law or by Order of dismissal whichever occurs first Only this Court call void modifY or dismiss this Order Either party may ask tbis Court to change or dismiss this Order

3 A person commits the offense of Aggravated Stalking when such person ill violation of a temporary or permanent protective Order prohibiting this behavior follows places unde surveillance or contacts Petitioner on public orprivate property for the purpose of harassing and intimidating the other person This activity can subject the Respondent to arrest and prosecution forfelony Aggravated Stalking which carries penalties ofimprisonment fornotl less than 1 year nor more than 10 years and a fine of up to $1000000

6

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Respondent _____________________~___

THEREFORE Petitioner asks

(a) That the Court set a hearing no later than thirty (30) days fi-om the filing of the Petition and direct Respondent to appear before this Court and show any reasons why the demands of the Petitioner should 110t be granted

(b) That the Respondent be served a copy ofthis Petition and Ex Palte Protective Order as required by law

(c) That this Court direct law enforcement to enforce this Order

(d) That this Court direct Respondent to stop abusing harassing and intimidating Petitioner andor Petitioner=s children

(e) That this Court restrain and enjoin Respondent from having any direct or indirect contact with the Petitioner andor Petitioners children

(f) That this Court order that Respondent be enjoined from approaching within __ yards of Petitioner

(g) That this Court make findings offact and conclusions of law concerning the issues in this case

(h) That Petitioner have such other and further relief as the COLlli may deem just and proper

(i) That this Court issue Family Violence Ex Parte and Twelve Month Protective Orders to

Check the following paragraphs that apply to your case Fill ill the information needed by each paragraph you check

o award Petitioner temporary sole legal and physical custody of the minor children

o order Respondent to vacate the family residence at - - - --instanter

C grant Petitioner exclusive temporary LIse and possession oftile family residence at __

4

_______________and alJ personal property ofthe palties located at the family residence and Petitioner=s current residence with the exception ofRespondent=s personal clothing that law enforcement (sheriff or police department) assist Petitioner in returning to the family residence and in ensuring that the Respondent vacates said residence and that all keys garage door openers and other security devices to the family residence are secured and given to the Petitioner

o order Respondent to provide suitable alternate housing for Petitioner andor Petitioner=s children

o order Respondent to stay away fiom Petitioner=s and 01 Petitioner=s minor children=s place of residence place of employment andor school

o order Respondent=s visitation with the minor children be limited to no visitation or

D order Respondent to pay to Petitioner child support for the minor children

o order Respondent to pay spousal support for Petitioner

I I award the Petitioner costs and attorney=s fees for having to bring this action

D order that Petitioner=s current address be kept confidential

Dmiddot enjoin and restrain Respondent from selling disposing or encumbering trading contracting to sell or otherwise disposing or removing from the jurisdiction of this Court any of the property ofPetitioner or of the parties except in the ordinary course of business

o enjoin and restrain Respondent from disconnecting the home utilities changing andor canceling auto health or life insurance for Respondent Petitioner andor the Petitioner=s minor children andor interfering with Petitioner=s or the Petitioner=s minor children=s mail

o grant Petitioner the use of the following automobile Make Model Year__ and law enforcement (sheriff or police department) ensure that all keys to said vehicle be immediately returned to Petitioner

o permit Petitioner to remove the following property from the residence for the exclusive use by Petitioner andor the minor chiJdren _

and law enforcement~_____(sheriff or police depal1ment) be ordered to assist the Petitioner during this removal

5

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THE SUPERIOR COURT FOR THE COUNTY OF ____F_L_O_Y_D___

STATE OF GEORGIA

J Petitioner J Civil Action File

J J No ____________________

] J

Respondent ]

VERIFICATION

Personally appeared who being duly sworn states that shehe is the Petitioner in the above styled case and that the facts set forth in the foregoing Petition for Temporary Protective Order are true and correct

Petitioner

Address ----~-----------------

City State _____________________

Phone (Do not give current address if confidential give alternative address)

Sworn and subscribed before me this ___ day of__________________

NOTARY PUBLIC My commission expires

OR] Number _0_5_7____

THE SUPERIOR COURT FOR THE COUNTY OF Floyd------shy

STATE OF GEORGIA

Petitioner Civil Action File v

Respondent

FAMlL Y VIOLENCE EX PARTE PROTECTIVE ORDER

The Petitioner having prayed pursuant to OCGA sectsect 19-13-1 et gm that a Protective Order be issued and alleged that Respondent has committed acts of Family Violence and that Petitioner is in reasonable fear of the Petitioners safety and the safety of Petitioners children and it appearing to the Court that probable cause exists that family violence has occurred in the past and may occur in the future IT IS HEREBY ORDERED AND ADJUDGED

1 That these proceedings be filed in the office of the Clerk of this COUlt

2 That this Order applies in every county throughout the state and it shall be the duty ofevery court and every law enforcement official to enforce and carry out the provisions ofthis Order pursuant to OeGA sect 19-134(d) Law Enforcement officers may use their arrest powers pursuant to 0 CGA sectsect 19-13-6 and 174-20 to enforce the tetms of this Order

3 That a copy of this Order be given to law enforcement and the Respondent be served with a copy of this Order and Petition for Temporary Protective Order instanter

4 iThat the Respondent appear before this Court on the _ day of

i---- ____ 20__ at m in room of the 1_______ County Courthouse at ____________

to show cause why the requests of the Petitioner should not be granted

CIVIL ACTION FILE NO ______

5 That Respondent is hereby enjoined and restrained from doing or attempting [peoOI) to do or threatening to do any act of injury maltreating molesting following harassing

hanning or abusing the Petitioner andor the minor children in any manner Respondent is not to intelfere with Petitioners travel transportation or communication Respondent shall not follow place under surveillance or contact the Petitioner at any place of the Petitioner for the purpose of harassing and intimidating the Petitioner

6 That the Respondent is enjoined and restrained from doing or threatening to do [peo02) any act of injury maltreating molesting harassing hanning or abusing the Petitioners

fumily or household

7 That this Court determined that it had jurisdiction over the parties and the subject matter under the laws of the State of Georgia and the Court ordered that the Respondent be given reasonable notice and opportunity to be heard sufficient to protect the Respondents due process rights This Order shall be presumed valid and pursuant to 18 USC sect 2265(a) shall be accorded fuJI faith and credit by any other state or local jurisdiction and shall be enforced as if an Order of the enforcing state or jurisdiction

ONLY THE FOLLOWING THAT ARE INITIALED BY THE JUDGE SHALL APPLY

8 That until further Order by this Court Petitioner is awarded sole and exclusive use [peo03) ofthe family residence at _____________~______

9 Respondent is ordered to leave the family residence immediately and law enforcement _______ (sheriff or police department) is ordered to assist Petitioner in returning to the family residence and the removal of tile Respondent Respondent is to immediately surrender to law enforcement (sheriff or police department) all and any keys garage door openers and other security devices to the fami ly residence and law enforcement is to insure that these are given to the Petitioner

10 Respondent is ordered to provide suitable alternate housing for Petitioner andor Petitioners children by _____________

11 Petitioners address is ordered to be kept confidential

2

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middot

12 [pen04]

13

[peoOl04]

14 [peoOS]

15 [peo09]

[peo06]

16

17

CIVIL ACTION FILE NO _____

Respondent is ordered to stay away from Petitioners and Petitioners minor childrens residence at and workplace at or school and any subsequent residence or workplace or school of Petitioner andlor Petitioners minor children

That until further Order of this Court Respondent is restrained and enjoined fiom

approaching within ___ yards of Petitioner andor Petitioners minor children

Respondent is ordered not to have any contact direct indirect or through another person with Petitioner by telephone pager fax e-mail or any other means of communication except as specified in this Order

That Petitioner is awarded tempora)1 cListody of the minor children namely yaB sex yaB sex yaB ______ sex ___ yaB ________ sex ___

Respondent is ordered not to interfere with the physical custody of the childreno

Check here only ifRespondent is awarded temporary cListody of childreno

That Respondent is ordered to pay temporary child support for the minor childlren to Petitioner in the amount of every beginning ____ All payments shall be made by or to __ income deduction order

__ child support receiver __ by mail directly to the Petitioner

or

That Respondent is ordered to pay temporary support for the Petitioner in the amount of $ every beginning ___________ All payments shall be made by or to __ income deduction order

__ child SUppOIt receiver by mail directly to the Petitioner

or

3

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CIVIL ACTION FILE NO _____

18 That Respondent only when accompanied by local law enforcement shall be able to remove hislher clothing and personal items from the residence as follows

On _____________20__ at ____ m

J 9 That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to sell encumber trade damage contract to sell 01

otherwise dispose of or remove fiom the jurisdiction of this Court any of the property or pets of the Petitioner or joint property or pets of the parties except in the ordinary course of business

20 That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to disconnect or have disconnected the home utilities change or have changed andor cancel or have canceled auto health or life insurance for Respondent Petitioner andor Petitioners children or interfere with Respondent Petitioners andor Petitioners childrensmail

21 That Petitioner is awarded temporary sole possession ofthe vehic1e Make Model Year Color Respondent shall immediately sunender all keys proof of insurance and registration to this vehicle to law enforcement and law enforcement shall immediately turn over said items to Petitioner

22 That Petitioner shall be allowed to remove the following property fiom the family residence for Petitioner andor Petitioners childrens use

On 20__ at and law enforcement (sheriff or police department) is hereby ordered to assist the Petitioner during this removal

23 That Respondent shall be required to rerum the following property for Petitioner andor Petitioners childrens use

________________________ On

_____________ 20__ at and law enforcement ________________ (sheriff or police depaltment) is hereby ordered to

-- - - --lt- -- --assisrthe-Petitionerwith this rerum - - ---- shy

4

CIVIL ACTION FILE NO ~____

24 1t is further Ordered

[pooOS]

SO ORDERED this __ day 20 --~-----

JUDGE SUPERIOR COURT _Floyd County

Print or stamp Judges name

Violation of the above Order may be punishable by arrest

5

CIVIL ACTION F1LE NO __

NOTICE TO RESPONDENT 1 Violation of this Order may result ill immediate arrest and criminal prosecution that may

result in jail time andor fines andlor may subject you to prosecution and penalties for contempt of court

2 This Ordershall remain in effect unless specifically superceded by a subsequent signed and filed Order by operation of law or by Order of dismissal whichever occurs first Only this Court call void modifY or dismiss this Order Either party may ask tbis Court to change or dismiss this Order

3 A person commits the offense of Aggravated Stalking when such person ill violation of a temporary or permanent protective Order prohibiting this behavior follows places unde surveillance or contacts Petitioner on public orprivate property for the purpose of harassing and intimidating the other person This activity can subject the Respondent to arrest and prosecution forfelony Aggravated Stalking which carries penalties ofimprisonment fornotl less than 1 year nor more than 10 years and a fine of up to $1000000

6

_______________and alJ personal property ofthe palties located at the family residence and Petitioner=s current residence with the exception ofRespondent=s personal clothing that law enforcement (sheriff or police department) assist Petitioner in returning to the family residence and in ensuring that the Respondent vacates said residence and that all keys garage door openers and other security devices to the family residence are secured and given to the Petitioner

o order Respondent to provide suitable alternate housing for Petitioner andor Petitioner=s children

o order Respondent to stay away fiom Petitioner=s and 01 Petitioner=s minor children=s place of residence place of employment andor school

o order Respondent=s visitation with the minor children be limited to no visitation or

D order Respondent to pay to Petitioner child support for the minor children

o order Respondent to pay spousal support for Petitioner

I I award the Petitioner costs and attorney=s fees for having to bring this action

D order that Petitioner=s current address be kept confidential

Dmiddot enjoin and restrain Respondent from selling disposing or encumbering trading contracting to sell or otherwise disposing or removing from the jurisdiction of this Court any of the property ofPetitioner or of the parties except in the ordinary course of business

o enjoin and restrain Respondent from disconnecting the home utilities changing andor canceling auto health or life insurance for Respondent Petitioner andor the Petitioner=s minor children andor interfering with Petitioner=s or the Petitioner=s minor children=s mail

o grant Petitioner the use of the following automobile Make Model Year__ and law enforcement (sheriff or police department) ensure that all keys to said vehicle be immediately returned to Petitioner

o permit Petitioner to remove the following property from the residence for the exclusive use by Petitioner andor the minor chiJdren _

and law enforcement~_____(sheriff or police depal1ment) be ordered to assist the Petitioner during this removal

5

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THE SUPERIOR COURT FOR THE COUNTY OF ____F_L_O_Y_D___

STATE OF GEORGIA

J Petitioner J Civil Action File

J J No ____________________

] J

Respondent ]

VERIFICATION

Personally appeared who being duly sworn states that shehe is the Petitioner in the above styled case and that the facts set forth in the foregoing Petition for Temporary Protective Order are true and correct

Petitioner

Address ----~-----------------

City State _____________________

Phone (Do not give current address if confidential give alternative address)

Sworn and subscribed before me this ___ day of__________________

NOTARY PUBLIC My commission expires

OR] Number _0_5_7____

THE SUPERIOR COURT FOR THE COUNTY OF Floyd------shy

STATE OF GEORGIA

Petitioner Civil Action File v

Respondent

FAMlL Y VIOLENCE EX PARTE PROTECTIVE ORDER

The Petitioner having prayed pursuant to OCGA sectsect 19-13-1 et gm that a Protective Order be issued and alleged that Respondent has committed acts of Family Violence and that Petitioner is in reasonable fear of the Petitioners safety and the safety of Petitioners children and it appearing to the Court that probable cause exists that family violence has occurred in the past and may occur in the future IT IS HEREBY ORDERED AND ADJUDGED

1 That these proceedings be filed in the office of the Clerk of this COUlt

2 That this Order applies in every county throughout the state and it shall be the duty ofevery court and every law enforcement official to enforce and carry out the provisions ofthis Order pursuant to OeGA sect 19-134(d) Law Enforcement officers may use their arrest powers pursuant to 0 CGA sectsect 19-13-6 and 174-20 to enforce the tetms of this Order

3 That a copy of this Order be given to law enforcement and the Respondent be served with a copy of this Order and Petition for Temporary Protective Order instanter

4 iThat the Respondent appear before this Court on the _ day of

i---- ____ 20__ at m in room of the 1_______ County Courthouse at ____________

to show cause why the requests of the Petitioner should not be granted

CIVIL ACTION FILE NO ______

5 That Respondent is hereby enjoined and restrained from doing or attempting [peoOI) to do or threatening to do any act of injury maltreating molesting following harassing

hanning or abusing the Petitioner andor the minor children in any manner Respondent is not to intelfere with Petitioners travel transportation or communication Respondent shall not follow place under surveillance or contact the Petitioner at any place of the Petitioner for the purpose of harassing and intimidating the Petitioner

6 That the Respondent is enjoined and restrained from doing or threatening to do [peo02) any act of injury maltreating molesting harassing hanning or abusing the Petitioners

fumily or household

7 That this Court determined that it had jurisdiction over the parties and the subject matter under the laws of the State of Georgia and the Court ordered that the Respondent be given reasonable notice and opportunity to be heard sufficient to protect the Respondents due process rights This Order shall be presumed valid and pursuant to 18 USC sect 2265(a) shall be accorded fuJI faith and credit by any other state or local jurisdiction and shall be enforced as if an Order of the enforcing state or jurisdiction

ONLY THE FOLLOWING THAT ARE INITIALED BY THE JUDGE SHALL APPLY

8 That until further Order by this Court Petitioner is awarded sole and exclusive use [peo03) ofthe family residence at _____________~______

9 Respondent is ordered to leave the family residence immediately and law enforcement _______ (sheriff or police department) is ordered to assist Petitioner in returning to the family residence and the removal of tile Respondent Respondent is to immediately surrender to law enforcement (sheriff or police department) all and any keys garage door openers and other security devices to the fami ly residence and law enforcement is to insure that these are given to the Petitioner

10 Respondent is ordered to provide suitable alternate housing for Petitioner andor Petitioners children by _____________

11 Petitioners address is ordered to be kept confidential

2

---

------

middot

12 [pen04]

13

[peoOl04]

14 [peoOS]

15 [peo09]

[peo06]

16

17

CIVIL ACTION FILE NO _____

Respondent is ordered to stay away from Petitioners and Petitioners minor childrens residence at and workplace at or school and any subsequent residence or workplace or school of Petitioner andlor Petitioners minor children

That until further Order of this Court Respondent is restrained and enjoined fiom

approaching within ___ yards of Petitioner andor Petitioners minor children

Respondent is ordered not to have any contact direct indirect or through another person with Petitioner by telephone pager fax e-mail or any other means of communication except as specified in this Order

That Petitioner is awarded tempora)1 cListody of the minor children namely yaB sex yaB sex yaB ______ sex ___ yaB ________ sex ___

Respondent is ordered not to interfere with the physical custody of the childreno

Check here only ifRespondent is awarded temporary cListody of childreno

That Respondent is ordered to pay temporary child support for the minor childlren to Petitioner in the amount of every beginning ____ All payments shall be made by or to __ income deduction order

__ child support receiver __ by mail directly to the Petitioner

or

That Respondent is ordered to pay temporary support for the Petitioner in the amount of $ every beginning ___________ All payments shall be made by or to __ income deduction order

__ child SUppOIt receiver by mail directly to the Petitioner

or

3

-------

-----------------------

CIVIL ACTION FILE NO _____

18 That Respondent only when accompanied by local law enforcement shall be able to remove hislher clothing and personal items from the residence as follows

On _____________20__ at ____ m

J 9 That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to sell encumber trade damage contract to sell 01

otherwise dispose of or remove fiom the jurisdiction of this Court any of the property or pets of the Petitioner or joint property or pets of the parties except in the ordinary course of business

20 That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to disconnect or have disconnected the home utilities change or have changed andor cancel or have canceled auto health or life insurance for Respondent Petitioner andor Petitioners children or interfere with Respondent Petitioners andor Petitioners childrensmail

21 That Petitioner is awarded temporary sole possession ofthe vehic1e Make Model Year Color Respondent shall immediately sunender all keys proof of insurance and registration to this vehicle to law enforcement and law enforcement shall immediately turn over said items to Petitioner

22 That Petitioner shall be allowed to remove the following property fiom the family residence for Petitioner andor Petitioners childrens use

On 20__ at and law enforcement (sheriff or police department) is hereby ordered to assist the Petitioner during this removal

23 That Respondent shall be required to rerum the following property for Petitioner andor Petitioners childrens use

________________________ On

_____________ 20__ at and law enforcement ________________ (sheriff or police depaltment) is hereby ordered to

-- - - --lt- -- --assisrthe-Petitionerwith this rerum - - ---- shy

4

CIVIL ACTION FILE NO ~____

24 1t is further Ordered

[pooOS]

SO ORDERED this __ day 20 --~-----

JUDGE SUPERIOR COURT _Floyd County

Print or stamp Judges name

Violation of the above Order may be punishable by arrest

5

CIVIL ACTION F1LE NO __

NOTICE TO RESPONDENT 1 Violation of this Order may result ill immediate arrest and criminal prosecution that may

result in jail time andor fines andlor may subject you to prosecution and penalties for contempt of court

2 This Ordershall remain in effect unless specifically superceded by a subsequent signed and filed Order by operation of law or by Order of dismissal whichever occurs first Only this Court call void modifY or dismiss this Order Either party may ask tbis Court to change or dismiss this Order

3 A person commits the offense of Aggravated Stalking when such person ill violation of a temporary or permanent protective Order prohibiting this behavior follows places unde surveillance or contacts Petitioner on public orprivate property for the purpose of harassing and intimidating the other person This activity can subject the Respondent to arrest and prosecution forfelony Aggravated Stalking which carries penalties ofimprisonment fornotl less than 1 year nor more than 10 years and a fine of up to $1000000

6

-----------------------

THE SUPERIOR COURT FOR THE COUNTY OF ____F_L_O_Y_D___

STATE OF GEORGIA

J Petitioner J Civil Action File

J J No ____________________

] J

Respondent ]

VERIFICATION

Personally appeared who being duly sworn states that shehe is the Petitioner in the above styled case and that the facts set forth in the foregoing Petition for Temporary Protective Order are true and correct

Petitioner

Address ----~-----------------

City State _____________________

Phone (Do not give current address if confidential give alternative address)

Sworn and subscribed before me this ___ day of__________________

NOTARY PUBLIC My commission expires

OR] Number _0_5_7____

THE SUPERIOR COURT FOR THE COUNTY OF Floyd------shy

STATE OF GEORGIA

Petitioner Civil Action File v

Respondent

FAMlL Y VIOLENCE EX PARTE PROTECTIVE ORDER

The Petitioner having prayed pursuant to OCGA sectsect 19-13-1 et gm that a Protective Order be issued and alleged that Respondent has committed acts of Family Violence and that Petitioner is in reasonable fear of the Petitioners safety and the safety of Petitioners children and it appearing to the Court that probable cause exists that family violence has occurred in the past and may occur in the future IT IS HEREBY ORDERED AND ADJUDGED

1 That these proceedings be filed in the office of the Clerk of this COUlt

2 That this Order applies in every county throughout the state and it shall be the duty ofevery court and every law enforcement official to enforce and carry out the provisions ofthis Order pursuant to OeGA sect 19-134(d) Law Enforcement officers may use their arrest powers pursuant to 0 CGA sectsect 19-13-6 and 174-20 to enforce the tetms of this Order

3 That a copy of this Order be given to law enforcement and the Respondent be served with a copy of this Order and Petition for Temporary Protective Order instanter

4 iThat the Respondent appear before this Court on the _ day of

i---- ____ 20__ at m in room of the 1_______ County Courthouse at ____________

to show cause why the requests of the Petitioner should not be granted

CIVIL ACTION FILE NO ______

5 That Respondent is hereby enjoined and restrained from doing or attempting [peoOI) to do or threatening to do any act of injury maltreating molesting following harassing

hanning or abusing the Petitioner andor the minor children in any manner Respondent is not to intelfere with Petitioners travel transportation or communication Respondent shall not follow place under surveillance or contact the Petitioner at any place of the Petitioner for the purpose of harassing and intimidating the Petitioner

6 That the Respondent is enjoined and restrained from doing or threatening to do [peo02) any act of injury maltreating molesting harassing hanning or abusing the Petitioners

fumily or household

7 That this Court determined that it had jurisdiction over the parties and the subject matter under the laws of the State of Georgia and the Court ordered that the Respondent be given reasonable notice and opportunity to be heard sufficient to protect the Respondents due process rights This Order shall be presumed valid and pursuant to 18 USC sect 2265(a) shall be accorded fuJI faith and credit by any other state or local jurisdiction and shall be enforced as if an Order of the enforcing state or jurisdiction

ONLY THE FOLLOWING THAT ARE INITIALED BY THE JUDGE SHALL APPLY

8 That until further Order by this Court Petitioner is awarded sole and exclusive use [peo03) ofthe family residence at _____________~______

9 Respondent is ordered to leave the family residence immediately and law enforcement _______ (sheriff or police department) is ordered to assist Petitioner in returning to the family residence and the removal of tile Respondent Respondent is to immediately surrender to law enforcement (sheriff or police department) all and any keys garage door openers and other security devices to the fami ly residence and law enforcement is to insure that these are given to the Petitioner

10 Respondent is ordered to provide suitable alternate housing for Petitioner andor Petitioners children by _____________

11 Petitioners address is ordered to be kept confidential

2

---

------

middot

12 [pen04]

13

[peoOl04]

14 [peoOS]

15 [peo09]

[peo06]

16

17

CIVIL ACTION FILE NO _____

Respondent is ordered to stay away from Petitioners and Petitioners minor childrens residence at and workplace at or school and any subsequent residence or workplace or school of Petitioner andlor Petitioners minor children

That until further Order of this Court Respondent is restrained and enjoined fiom

approaching within ___ yards of Petitioner andor Petitioners minor children

Respondent is ordered not to have any contact direct indirect or through another person with Petitioner by telephone pager fax e-mail or any other means of communication except as specified in this Order

That Petitioner is awarded tempora)1 cListody of the minor children namely yaB sex yaB sex yaB ______ sex ___ yaB ________ sex ___

Respondent is ordered not to interfere with the physical custody of the childreno

Check here only ifRespondent is awarded temporary cListody of childreno

That Respondent is ordered to pay temporary child support for the minor childlren to Petitioner in the amount of every beginning ____ All payments shall be made by or to __ income deduction order

__ child support receiver __ by mail directly to the Petitioner

or

That Respondent is ordered to pay temporary support for the Petitioner in the amount of $ every beginning ___________ All payments shall be made by or to __ income deduction order

__ child SUppOIt receiver by mail directly to the Petitioner

or

3

-------

-----------------------

CIVIL ACTION FILE NO _____

18 That Respondent only when accompanied by local law enforcement shall be able to remove hislher clothing and personal items from the residence as follows

On _____________20__ at ____ m

J 9 That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to sell encumber trade damage contract to sell 01

otherwise dispose of or remove fiom the jurisdiction of this Court any of the property or pets of the Petitioner or joint property or pets of the parties except in the ordinary course of business

20 That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to disconnect or have disconnected the home utilities change or have changed andor cancel or have canceled auto health or life insurance for Respondent Petitioner andor Petitioners children or interfere with Respondent Petitioners andor Petitioners childrensmail

21 That Petitioner is awarded temporary sole possession ofthe vehic1e Make Model Year Color Respondent shall immediately sunender all keys proof of insurance and registration to this vehicle to law enforcement and law enforcement shall immediately turn over said items to Petitioner

22 That Petitioner shall be allowed to remove the following property fiom the family residence for Petitioner andor Petitioners childrens use

On 20__ at and law enforcement (sheriff or police department) is hereby ordered to assist the Petitioner during this removal

23 That Respondent shall be required to rerum the following property for Petitioner andor Petitioners childrens use

________________________ On

_____________ 20__ at and law enforcement ________________ (sheriff or police depaltment) is hereby ordered to

-- - - --lt- -- --assisrthe-Petitionerwith this rerum - - ---- shy

4

CIVIL ACTION FILE NO ~____

24 1t is further Ordered

[pooOS]

SO ORDERED this __ day 20 --~-----

JUDGE SUPERIOR COURT _Floyd County

Print or stamp Judges name

Violation of the above Order may be punishable by arrest

5

CIVIL ACTION F1LE NO __

NOTICE TO RESPONDENT 1 Violation of this Order may result ill immediate arrest and criminal prosecution that may

result in jail time andor fines andlor may subject you to prosecution and penalties for contempt of court

2 This Ordershall remain in effect unless specifically superceded by a subsequent signed and filed Order by operation of law or by Order of dismissal whichever occurs first Only this Court call void modifY or dismiss this Order Either party may ask tbis Court to change or dismiss this Order

3 A person commits the offense of Aggravated Stalking when such person ill violation of a temporary or permanent protective Order prohibiting this behavior follows places unde surveillance or contacts Petitioner on public orprivate property for the purpose of harassing and intimidating the other person This activity can subject the Respondent to arrest and prosecution forfelony Aggravated Stalking which carries penalties ofimprisonment fornotl less than 1 year nor more than 10 years and a fine of up to $1000000

6

OR] Number _0_5_7____

THE SUPERIOR COURT FOR THE COUNTY OF Floyd------shy

STATE OF GEORGIA

Petitioner Civil Action File v

Respondent

FAMlL Y VIOLENCE EX PARTE PROTECTIVE ORDER

The Petitioner having prayed pursuant to OCGA sectsect 19-13-1 et gm that a Protective Order be issued and alleged that Respondent has committed acts of Family Violence and that Petitioner is in reasonable fear of the Petitioners safety and the safety of Petitioners children and it appearing to the Court that probable cause exists that family violence has occurred in the past and may occur in the future IT IS HEREBY ORDERED AND ADJUDGED

1 That these proceedings be filed in the office of the Clerk of this COUlt

2 That this Order applies in every county throughout the state and it shall be the duty ofevery court and every law enforcement official to enforce and carry out the provisions ofthis Order pursuant to OeGA sect 19-134(d) Law Enforcement officers may use their arrest powers pursuant to 0 CGA sectsect 19-13-6 and 174-20 to enforce the tetms of this Order

3 That a copy of this Order be given to law enforcement and the Respondent be served with a copy of this Order and Petition for Temporary Protective Order instanter

4 iThat the Respondent appear before this Court on the _ day of

i---- ____ 20__ at m in room of the 1_______ County Courthouse at ____________

to show cause why the requests of the Petitioner should not be granted

CIVIL ACTION FILE NO ______

5 That Respondent is hereby enjoined and restrained from doing or attempting [peoOI) to do or threatening to do any act of injury maltreating molesting following harassing

hanning or abusing the Petitioner andor the minor children in any manner Respondent is not to intelfere with Petitioners travel transportation or communication Respondent shall not follow place under surveillance or contact the Petitioner at any place of the Petitioner for the purpose of harassing and intimidating the Petitioner

6 That the Respondent is enjoined and restrained from doing or threatening to do [peo02) any act of injury maltreating molesting harassing hanning or abusing the Petitioners

fumily or household

7 That this Court determined that it had jurisdiction over the parties and the subject matter under the laws of the State of Georgia and the Court ordered that the Respondent be given reasonable notice and opportunity to be heard sufficient to protect the Respondents due process rights This Order shall be presumed valid and pursuant to 18 USC sect 2265(a) shall be accorded fuJI faith and credit by any other state or local jurisdiction and shall be enforced as if an Order of the enforcing state or jurisdiction

ONLY THE FOLLOWING THAT ARE INITIALED BY THE JUDGE SHALL APPLY

8 That until further Order by this Court Petitioner is awarded sole and exclusive use [peo03) ofthe family residence at _____________~______

9 Respondent is ordered to leave the family residence immediately and law enforcement _______ (sheriff or police department) is ordered to assist Petitioner in returning to the family residence and the removal of tile Respondent Respondent is to immediately surrender to law enforcement (sheriff or police department) all and any keys garage door openers and other security devices to the fami ly residence and law enforcement is to insure that these are given to the Petitioner

10 Respondent is ordered to provide suitable alternate housing for Petitioner andor Petitioners children by _____________

11 Petitioners address is ordered to be kept confidential

2

---

------

middot

12 [pen04]

13

[peoOl04]

14 [peoOS]

15 [peo09]

[peo06]

16

17

CIVIL ACTION FILE NO _____

Respondent is ordered to stay away from Petitioners and Petitioners minor childrens residence at and workplace at or school and any subsequent residence or workplace or school of Petitioner andlor Petitioners minor children

That until further Order of this Court Respondent is restrained and enjoined fiom

approaching within ___ yards of Petitioner andor Petitioners minor children

Respondent is ordered not to have any contact direct indirect or through another person with Petitioner by telephone pager fax e-mail or any other means of communication except as specified in this Order

That Petitioner is awarded tempora)1 cListody of the minor children namely yaB sex yaB sex yaB ______ sex ___ yaB ________ sex ___

Respondent is ordered not to interfere with the physical custody of the childreno

Check here only ifRespondent is awarded temporary cListody of childreno

That Respondent is ordered to pay temporary child support for the minor childlren to Petitioner in the amount of every beginning ____ All payments shall be made by or to __ income deduction order

__ child support receiver __ by mail directly to the Petitioner

or

That Respondent is ordered to pay temporary support for the Petitioner in the amount of $ every beginning ___________ All payments shall be made by or to __ income deduction order

__ child SUppOIt receiver by mail directly to the Petitioner

or

3

-------

-----------------------

CIVIL ACTION FILE NO _____

18 That Respondent only when accompanied by local law enforcement shall be able to remove hislher clothing and personal items from the residence as follows

On _____________20__ at ____ m

J 9 That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to sell encumber trade damage contract to sell 01

otherwise dispose of or remove fiom the jurisdiction of this Court any of the property or pets of the Petitioner or joint property or pets of the parties except in the ordinary course of business

20 That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to disconnect or have disconnected the home utilities change or have changed andor cancel or have canceled auto health or life insurance for Respondent Petitioner andor Petitioners children or interfere with Respondent Petitioners andor Petitioners childrensmail

21 That Petitioner is awarded temporary sole possession ofthe vehic1e Make Model Year Color Respondent shall immediately sunender all keys proof of insurance and registration to this vehicle to law enforcement and law enforcement shall immediately turn over said items to Petitioner

22 That Petitioner shall be allowed to remove the following property fiom the family residence for Petitioner andor Petitioners childrens use

On 20__ at and law enforcement (sheriff or police department) is hereby ordered to assist the Petitioner during this removal

23 That Respondent shall be required to rerum the following property for Petitioner andor Petitioners childrens use

________________________ On

_____________ 20__ at and law enforcement ________________ (sheriff or police depaltment) is hereby ordered to

-- - - --lt- -- --assisrthe-Petitionerwith this rerum - - ---- shy

4

CIVIL ACTION FILE NO ~____

24 1t is further Ordered

[pooOS]

SO ORDERED this __ day 20 --~-----

JUDGE SUPERIOR COURT _Floyd County

Print or stamp Judges name

Violation of the above Order may be punishable by arrest

5

CIVIL ACTION F1LE NO __

NOTICE TO RESPONDENT 1 Violation of this Order may result ill immediate arrest and criminal prosecution that may

result in jail time andor fines andlor may subject you to prosecution and penalties for contempt of court

2 This Ordershall remain in effect unless specifically superceded by a subsequent signed and filed Order by operation of law or by Order of dismissal whichever occurs first Only this Court call void modifY or dismiss this Order Either party may ask tbis Court to change or dismiss this Order

3 A person commits the offense of Aggravated Stalking when such person ill violation of a temporary or permanent protective Order prohibiting this behavior follows places unde surveillance or contacts Petitioner on public orprivate property for the purpose of harassing and intimidating the other person This activity can subject the Respondent to arrest and prosecution forfelony Aggravated Stalking which carries penalties ofimprisonment fornotl less than 1 year nor more than 10 years and a fine of up to $1000000

6

CIVIL ACTION FILE NO ______

5 That Respondent is hereby enjoined and restrained from doing or attempting [peoOI) to do or threatening to do any act of injury maltreating molesting following harassing

hanning or abusing the Petitioner andor the minor children in any manner Respondent is not to intelfere with Petitioners travel transportation or communication Respondent shall not follow place under surveillance or contact the Petitioner at any place of the Petitioner for the purpose of harassing and intimidating the Petitioner

6 That the Respondent is enjoined and restrained from doing or threatening to do [peo02) any act of injury maltreating molesting harassing hanning or abusing the Petitioners

fumily or household

7 That this Court determined that it had jurisdiction over the parties and the subject matter under the laws of the State of Georgia and the Court ordered that the Respondent be given reasonable notice and opportunity to be heard sufficient to protect the Respondents due process rights This Order shall be presumed valid and pursuant to 18 USC sect 2265(a) shall be accorded fuJI faith and credit by any other state or local jurisdiction and shall be enforced as if an Order of the enforcing state or jurisdiction

ONLY THE FOLLOWING THAT ARE INITIALED BY THE JUDGE SHALL APPLY

8 That until further Order by this Court Petitioner is awarded sole and exclusive use [peo03) ofthe family residence at _____________~______

9 Respondent is ordered to leave the family residence immediately and law enforcement _______ (sheriff or police department) is ordered to assist Petitioner in returning to the family residence and the removal of tile Respondent Respondent is to immediately surrender to law enforcement (sheriff or police department) all and any keys garage door openers and other security devices to the fami ly residence and law enforcement is to insure that these are given to the Petitioner

10 Respondent is ordered to provide suitable alternate housing for Petitioner andor Petitioners children by _____________

11 Petitioners address is ordered to be kept confidential

2

---

------

middot

12 [pen04]

13

[peoOl04]

14 [peoOS]

15 [peo09]

[peo06]

16

17

CIVIL ACTION FILE NO _____

Respondent is ordered to stay away from Petitioners and Petitioners minor childrens residence at and workplace at or school and any subsequent residence or workplace or school of Petitioner andlor Petitioners minor children

That until further Order of this Court Respondent is restrained and enjoined fiom

approaching within ___ yards of Petitioner andor Petitioners minor children

Respondent is ordered not to have any contact direct indirect or through another person with Petitioner by telephone pager fax e-mail or any other means of communication except as specified in this Order

That Petitioner is awarded tempora)1 cListody of the minor children namely yaB sex yaB sex yaB ______ sex ___ yaB ________ sex ___

Respondent is ordered not to interfere with the physical custody of the childreno

Check here only ifRespondent is awarded temporary cListody of childreno

That Respondent is ordered to pay temporary child support for the minor childlren to Petitioner in the amount of every beginning ____ All payments shall be made by or to __ income deduction order

__ child support receiver __ by mail directly to the Petitioner

or

That Respondent is ordered to pay temporary support for the Petitioner in the amount of $ every beginning ___________ All payments shall be made by or to __ income deduction order

__ child SUppOIt receiver by mail directly to the Petitioner

or

3

-------

-----------------------

CIVIL ACTION FILE NO _____

18 That Respondent only when accompanied by local law enforcement shall be able to remove hislher clothing and personal items from the residence as follows

On _____________20__ at ____ m

J 9 That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to sell encumber trade damage contract to sell 01

otherwise dispose of or remove fiom the jurisdiction of this Court any of the property or pets of the Petitioner or joint property or pets of the parties except in the ordinary course of business

20 That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to disconnect or have disconnected the home utilities change or have changed andor cancel or have canceled auto health or life insurance for Respondent Petitioner andor Petitioners children or interfere with Respondent Petitioners andor Petitioners childrensmail

21 That Petitioner is awarded temporary sole possession ofthe vehic1e Make Model Year Color Respondent shall immediately sunender all keys proof of insurance and registration to this vehicle to law enforcement and law enforcement shall immediately turn over said items to Petitioner

22 That Petitioner shall be allowed to remove the following property fiom the family residence for Petitioner andor Petitioners childrens use

On 20__ at and law enforcement (sheriff or police department) is hereby ordered to assist the Petitioner during this removal

23 That Respondent shall be required to rerum the following property for Petitioner andor Petitioners childrens use

________________________ On

_____________ 20__ at and law enforcement ________________ (sheriff or police depaltment) is hereby ordered to

-- - - --lt- -- --assisrthe-Petitionerwith this rerum - - ---- shy

4

CIVIL ACTION FILE NO ~____

24 1t is further Ordered

[pooOS]

SO ORDERED this __ day 20 --~-----

JUDGE SUPERIOR COURT _Floyd County

Print or stamp Judges name

Violation of the above Order may be punishable by arrest

5

CIVIL ACTION F1LE NO __

NOTICE TO RESPONDENT 1 Violation of this Order may result ill immediate arrest and criminal prosecution that may

result in jail time andor fines andlor may subject you to prosecution and penalties for contempt of court

2 This Ordershall remain in effect unless specifically superceded by a subsequent signed and filed Order by operation of law or by Order of dismissal whichever occurs first Only this Court call void modifY or dismiss this Order Either party may ask tbis Court to change or dismiss this Order

3 A person commits the offense of Aggravated Stalking when such person ill violation of a temporary or permanent protective Order prohibiting this behavior follows places unde surveillance or contacts Petitioner on public orprivate property for the purpose of harassing and intimidating the other person This activity can subject the Respondent to arrest and prosecution forfelony Aggravated Stalking which carries penalties ofimprisonment fornotl less than 1 year nor more than 10 years and a fine of up to $1000000

6

---

------

middot

12 [pen04]

13

[peoOl04]

14 [peoOS]

15 [peo09]

[peo06]

16

17

CIVIL ACTION FILE NO _____

Respondent is ordered to stay away from Petitioners and Petitioners minor childrens residence at and workplace at or school and any subsequent residence or workplace or school of Petitioner andlor Petitioners minor children

That until further Order of this Court Respondent is restrained and enjoined fiom

approaching within ___ yards of Petitioner andor Petitioners minor children

Respondent is ordered not to have any contact direct indirect or through another person with Petitioner by telephone pager fax e-mail or any other means of communication except as specified in this Order

That Petitioner is awarded tempora)1 cListody of the minor children namely yaB sex yaB sex yaB ______ sex ___ yaB ________ sex ___

Respondent is ordered not to interfere with the physical custody of the childreno

Check here only ifRespondent is awarded temporary cListody of childreno

That Respondent is ordered to pay temporary child support for the minor childlren to Petitioner in the amount of every beginning ____ All payments shall be made by or to __ income deduction order

__ child support receiver __ by mail directly to the Petitioner

or

That Respondent is ordered to pay temporary support for the Petitioner in the amount of $ every beginning ___________ All payments shall be made by or to __ income deduction order

__ child SUppOIt receiver by mail directly to the Petitioner

or

3

-------

-----------------------

CIVIL ACTION FILE NO _____

18 That Respondent only when accompanied by local law enforcement shall be able to remove hislher clothing and personal items from the residence as follows

On _____________20__ at ____ m

J 9 That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to sell encumber trade damage contract to sell 01

otherwise dispose of or remove fiom the jurisdiction of this Court any of the property or pets of the Petitioner or joint property or pets of the parties except in the ordinary course of business

20 That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to disconnect or have disconnected the home utilities change or have changed andor cancel or have canceled auto health or life insurance for Respondent Petitioner andor Petitioners children or interfere with Respondent Petitioners andor Petitioners childrensmail

21 That Petitioner is awarded temporary sole possession ofthe vehic1e Make Model Year Color Respondent shall immediately sunender all keys proof of insurance and registration to this vehicle to law enforcement and law enforcement shall immediately turn over said items to Petitioner

22 That Petitioner shall be allowed to remove the following property fiom the family residence for Petitioner andor Petitioners childrens use

On 20__ at and law enforcement (sheriff or police department) is hereby ordered to assist the Petitioner during this removal

23 That Respondent shall be required to rerum the following property for Petitioner andor Petitioners childrens use

________________________ On

_____________ 20__ at and law enforcement ________________ (sheriff or police depaltment) is hereby ordered to

-- - - --lt- -- --assisrthe-Petitionerwith this rerum - - ---- shy

4

CIVIL ACTION FILE NO ~____

24 1t is further Ordered

[pooOS]

SO ORDERED this __ day 20 --~-----

JUDGE SUPERIOR COURT _Floyd County

Print or stamp Judges name

Violation of the above Order may be punishable by arrest

5

CIVIL ACTION F1LE NO __

NOTICE TO RESPONDENT 1 Violation of this Order may result ill immediate arrest and criminal prosecution that may

result in jail time andor fines andlor may subject you to prosecution and penalties for contempt of court

2 This Ordershall remain in effect unless specifically superceded by a subsequent signed and filed Order by operation of law or by Order of dismissal whichever occurs first Only this Court call void modifY or dismiss this Order Either party may ask tbis Court to change or dismiss this Order

3 A person commits the offense of Aggravated Stalking when such person ill violation of a temporary or permanent protective Order prohibiting this behavior follows places unde surveillance or contacts Petitioner on public orprivate property for the purpose of harassing and intimidating the other person This activity can subject the Respondent to arrest and prosecution forfelony Aggravated Stalking which carries penalties ofimprisonment fornotl less than 1 year nor more than 10 years and a fine of up to $1000000

6

-------

-----------------------

CIVIL ACTION FILE NO _____

18 That Respondent only when accompanied by local law enforcement shall be able to remove hislher clothing and personal items from the residence as follows

On _____________20__ at ____ m

J 9 That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to sell encumber trade damage contract to sell 01

otherwise dispose of or remove fiom the jurisdiction of this Court any of the property or pets of the Petitioner or joint property or pets of the parties except in the ordinary course of business

20 That (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to disconnect or have disconnected the home utilities change or have changed andor cancel or have canceled auto health or life insurance for Respondent Petitioner andor Petitioners children or interfere with Respondent Petitioners andor Petitioners childrensmail

21 That Petitioner is awarded temporary sole possession ofthe vehic1e Make Model Year Color Respondent shall immediately sunender all keys proof of insurance and registration to this vehicle to law enforcement and law enforcement shall immediately turn over said items to Petitioner

22 That Petitioner shall be allowed to remove the following property fiom the family residence for Petitioner andor Petitioners childrens use

On 20__ at and law enforcement (sheriff or police department) is hereby ordered to assist the Petitioner during this removal

23 That Respondent shall be required to rerum the following property for Petitioner andor Petitioners childrens use

________________________ On

_____________ 20__ at and law enforcement ________________ (sheriff or police depaltment) is hereby ordered to

-- - - --lt- -- --assisrthe-Petitionerwith this rerum - - ---- shy

4

CIVIL ACTION FILE NO ~____

24 1t is further Ordered

[pooOS]

SO ORDERED this __ day 20 --~-----

JUDGE SUPERIOR COURT _Floyd County

Print or stamp Judges name

Violation of the above Order may be punishable by arrest

5

CIVIL ACTION F1LE NO __

NOTICE TO RESPONDENT 1 Violation of this Order may result ill immediate arrest and criminal prosecution that may

result in jail time andor fines andlor may subject you to prosecution and penalties for contempt of court

2 This Ordershall remain in effect unless specifically superceded by a subsequent signed and filed Order by operation of law or by Order of dismissal whichever occurs first Only this Court call void modifY or dismiss this Order Either party may ask tbis Court to change or dismiss this Order

3 A person commits the offense of Aggravated Stalking when such person ill violation of a temporary or permanent protective Order prohibiting this behavior follows places unde surveillance or contacts Petitioner on public orprivate property for the purpose of harassing and intimidating the other person This activity can subject the Respondent to arrest and prosecution forfelony Aggravated Stalking which carries penalties ofimprisonment fornotl less than 1 year nor more than 10 years and a fine of up to $1000000

6

CIVIL ACTION FILE NO ~____

24 1t is further Ordered

[pooOS]

SO ORDERED this __ day 20 --~-----

JUDGE SUPERIOR COURT _Floyd County

Print or stamp Judges name

Violation of the above Order may be punishable by arrest

5

CIVIL ACTION F1LE NO __

NOTICE TO RESPONDENT 1 Violation of this Order may result ill immediate arrest and criminal prosecution that may

result in jail time andor fines andlor may subject you to prosecution and penalties for contempt of court

2 This Ordershall remain in effect unless specifically superceded by a subsequent signed and filed Order by operation of law or by Order of dismissal whichever occurs first Only this Court call void modifY or dismiss this Order Either party may ask tbis Court to change or dismiss this Order

3 A person commits the offense of Aggravated Stalking when such person ill violation of a temporary or permanent protective Order prohibiting this behavior follows places unde surveillance or contacts Petitioner on public orprivate property for the purpose of harassing and intimidating the other person This activity can subject the Respondent to arrest and prosecution forfelony Aggravated Stalking which carries penalties ofimprisonment fornotl less than 1 year nor more than 10 years and a fine of up to $1000000

6

CIVIL ACTION F1LE NO __

NOTICE TO RESPONDENT 1 Violation of this Order may result ill immediate arrest and criminal prosecution that may

result in jail time andor fines andlor may subject you to prosecution and penalties for contempt of court

2 This Ordershall remain in effect unless specifically superceded by a subsequent signed and filed Order by operation of law or by Order of dismissal whichever occurs first Only this Court call void modifY or dismiss this Order Either party may ask tbis Court to change or dismiss this Order

3 A person commits the offense of Aggravated Stalking when such person ill violation of a temporary or permanent protective Order prohibiting this behavior follows places unde surveillance or contacts Petitioner on public orprivate property for the purpose of harassing and intimidating the other person This activity can subject the Respondent to arrest and prosecution forfelony Aggravated Stalking which carries penalties ofimprisonment fornotl less than 1 year nor more than 10 years and a fine of up to $1000000

6

ORI Number ____---__

SC-16

THE SUPERIOR COURT FOR THE COUNTY OF ______

STATE OF GEORGIA

Petitioner Civil Action File

v No _________

Respondent

FAMILY VIOLENCE TWELVE MONTH PROTECTIVE ORDER

A hearing was held on this matter on 20__ for which the Respondent had notice as required by law and at which the Respondent appeared andlor had the opportunity to be heard and the Petitioner requested that the Protective Order entered in this case be continued Having heard the evidence presented reviewed the petition and the entire record concerning this case and for good cause shown IT IS HEREBY ORDERED AND ADJUDGED

1 That these proceedings be filed in the office of the Clerk of this Court

2 That this Order applies in every county throughout the state and it shall be the duty of every court and every law enforcement official to enforce and carry out the provisions of this Order pursuant to OCGA sect 19-13-4 (d) Law enforcement officers may use their arrest powers pursuant to OCGA sectsect 19-13-6 and 17-4-20 to enforce the terms of this Order

3 This Order shall be in effect for up to twelve (12) months from __________ 20 __until __________ 20 __

4 That the Respondent has violated the Family Violence Act OCGA sect 19-13-1 [peoOI] et seq by committing family violence has placed the Petitioner in reasonable fear for

Petitioners safety and represents a credible threat to the physical safety of Petitioner andor Petitioners childreno Respondent is hereby enjoined and restrained from doing or attempting to do or threatening to do any act of injury maltreating molesting following harassing harming or abusing the Petitioner andor the minor children in any manner Respondent is not to interfere with Petitioners travel transportation or communication Respondent shall not follow place under surveillance or contact the Petitioner at any place ofthe Petitioner for the purpose of harassing and intimidating the Petitioner

5 That the Respondent is enjoined and restrained from doing or attempting to do or [pco02] threatening to do any act of injury maltreating molesting harassing harming or

abusing the Petitioners family or household

1

---CIVIL ACTION FILE NO

6 That this Court determined that it had jurisdiction over the parties and the subject matter under the laws of the State of Georgia and Respondent received reasonable notice and had the opportunity to be heard before this Order was issued sufficient to protect the Respondents due process rights and this Order shall be presumed valid and pursuant to 18 USc sect 2265(a) shall be accorded full faith and credit by any other state or local jurisdiction and shall be enforced as if an Order of the enforcing state or jurisdiction

ONLY THE FOLLOWING THATARE INITIALED BY THE JUDGE SHALL APPLY

7 Petitioner is awarded sole and exclusive possession of the residence at _____

[pco03]

8 Respondent is ordered to leave the family residence immediately and law enforcement at (sheriff or police department) is ordered to assist Petitioner in returning to the family residence and the removal of the Respondent Respondent shall immediately surrender to law enforcement (sheriff or police department) all and any keys garage door openers and other security devices to the family residence and law enforcement shall ensure that these are given to the Petitioner

9 Respondent is ordered to stay away from Petitioners and Petitioners childrens [pco04] residence and workplace andor school and any subsequent residence or workplace or

school of Petitioner andor Petitioners minor childreno

__ 10 Respondent is ordered to provide suitable alternate housing for Petitioner andor Petitioners children by 20 __

11 That Respondent is restrained and enjoined from approaching within _____ yards [pcoOI04] of Petitioner andor Petitioners minor children

12 Respondent is ordered not to have any contact direct indirect or through another [pco05] person with Petitioner by telephone fax e-mail or any other means of communication

except as specified in this Order

13 That Petitioner is awarded temporary custody of the minor children namely [pco09] YOB sex ____

YOB _____ sex _____

YOB _____ sex _____

YOB sex ____ Respondent is ordered not to interfere with the physical custody of the minor childreno

[pco06] Initial here only ifRespondent is awarded temporary custody of the childreno

2

---CIVIL ACTION FILE NO

6 That this Court determined that it had jurisdiction over the parties and the subject matter under the laws of the State of Georgia and Respondent received reasonable notice and had the opportunity to be heard before this Order was issued sufficient to protect the Respondents due process rights and this Order shall be presumed valid and pursuant to 18 USc sect 2265(a) shall be accorded full faith and credit by any other state or local jurisdiction and shall be enforced as if an Order of the enforcing state or jurisdiction

ONLY THE FOLLOWING THATARE INITIALED BY THE JUDGE SHALL APPLY

7 Petitioner is awarded sole and exclusive possession of the residence at _____

[pco03]

8 Respondent is ordered to leave the family residence immediately and law enforcement at (sheriff or police department) is ordered to assist Petitioner in returning to the family residence and the removal of the Respondent Respondent shall immediately surrender to law enforcement (sheriff or police department) all and any keys garage door openers and other security devices to the family residence and law enforcement shall ensure that these are given to the Petitioner

9 Respondent is ordered to stay away from Petitioners and Petitioners childrens [pco04] residence and workplace andor school and any subsequent residence or workplace or

school of Petitioner andor Petitioners minor childreno

__ 10 Respondent is ordered to provide suitable alternate housing for Petitioner andor Petitioners children by 20 __

11 That Respondent is restrained and enjoined from approaching within _____ yards [pcoOI04] of Petitioner andor Petitioners minor children

12 Respondent is ordered not to have any contact direct indirect or through another [pco05] person with Petitioner by telephone fax e-mail or any other means of communication

except as specified in this Order

13 That Petitioner is awarded temporary custody of the minor children namely [pco09] YOB sex ____

YOB _____ sex _____

YOB _____ sex _____

YOB sex ____ Respondent is ordered not to interfere with the physical custody of the minor childreno

[pco06] Initial here only ifRespondent is awarded temporary custody of the childreno

2

--

----------------------

-------------------

CIVIL ACTION FILE NO ________

14 The ______ shall pay to the _______ for the support of the minor

children the sum Dollars ($ ) per ____________ beginning __________

All payments are to be made by or to income deduction order __ child support receiver __ by mail directly to the Petitioner

or

15 Respondent is ordered to pay temporary support for the Petitioner in the amount of every beginning __________

20

All payments are to be made by or to __ income deduction order __ child support receiver

by mail directly to the Petitioner or

16 Respondent shall have visitation with the minor children according to the following schedule beginning _________________

no visitation

no visitation until 20 __

__ supervised visitation supervised by a third party as follows

__ visitation every other weekend from Friday at 6 pm until Sunday at 6 pm

beginning~------------------other visitation

circumstances concerning how Respondent shall pick up and return the minor children shall be

Strict compliance with this visitation provision shall not be a violation of the restraining provisions of this Order

__ 17 Respondent only when accompanied by local law enforcement shall be able to remove hislher clothing and personal items from the residence as follows

On _________20__m___---_

__ 18 (Respondent)(Petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to sell encumber trade damage contract to sell or otherwise dispose of or remove from the jurisdiction of this Court any of the property or pets of the Petitioner or joint property or pets of the parties except in the ordinary course of

3

--

-----

----------------------------

-----------------------------

--------

business CIVIL ACTION FILE NO ________

19 (Respondent)(petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to disconnect or have disconnected home utilities change or have changed andor cancel or have canceled auto health or life insurance for Respondent Petitioner andor Petitioners children or interfere with Respondent Petitioners andor Petitioners childrens mail

__ 20 Petitioner shall have sole exclusive temporary possession of the vehicle Make Model Year Color Respondent shall immediately surrender all keys proof of insurance and registration to this vehicle to law enforcement and law enforcement shall immediately tum over said items to Petitioner

__ 21 Petitioner shall be allowed to remove the following property from the family residence for Petitioner andor Petitioners childrens use

On 20 at and law enforcement ___________ (sheriff or police department) is hereby ordered to assist the Petitioner during this removaL

22 Respondent is ordered to undergo alcohoVdrug abuse evaluation and follow the recommended treatment

__ 23 That Respondent shall be required to return the following property for Petitioner andor Petitioners childrens use

On 20 at __m and law enforcement ________ (sheriff or police department) is hereby ordered to assist the Petitioner during this return

24 Petitioner is awarded costs and attorney fees in the amount of

25 FAMILY VIOLENCE INTERVENTION PROGRAM

It is further Ordered that the Respondent shall make arrangements to begin a certified family violence intervention program (FVIP) within fourteen (14) days ofthe signing ofthis Order or if appropriate within fourteen (14) days upon release from incarceration A list of local certified agencies will be given to the Respondent with this Order Furthermore Respondent shall appear before this court __________---____- 20 at m for a hearing on the status ofhislher application attendance andor completion of the FVIP At that hearing Respondent is ordered to present to this court a written status report from the agency providing the certified FVIP The status report shall detail Respondents application attendance andor completion of or failure to apply attend andor complete the FVIP and shall be signed by an officer of the agency

4

---

OR CNIL ACTION FILE NO ________

OR

Respondent is ordered to undergo a certified family violence intervention program and comply with the attached compliance form

Respondent is ordered to undergo a certified family violence intervention program

OR

Respondent is not ordered to undergo a certified family violence intervention program and the following reasons exist

26 Petitionerprotected party is either a spouse former spouse parent of a common (pea07] child Petitioners child child of Respondent cohabitates or has cohabited with

Respondent and qualifies for 18 USC sect 922(g) It is further ordered that the Respondent shall not possess or purchase a firearm or ammunition as restricted by federal law under 18 USC sect 922(g)(8)

27 It is further Ordered

[peaOS]

SO ORDERED this day _________________20__ __

JUDGE SUPERIOR COURT

__________ County

Print or stamp Judges name

Violation of the above Order may be punishable by arrest

5

CIVIL ACTION FILE NO _______

NOTICE TO RESPONDENT

1 Violation of this Order may result in immediate arrest and criminal prosecution that may result in jail time andor fines andor may subject you to prosecution and penalties for contempt of court 2 This Order shall remain in effect unless specifically superceded by a subsequent Order signed and filed by operation of law or by Order of dismissal whichever occurs first Only this Court can void modify or dismiss this Order Either party may ask this Court to change or dismiss this Order 3 If after a hearing of which the Respondent received notice and opportunity to participate a protective order is issued which restrains Respondent from harassing stalking or threatening an intimate partner Respondent is prohibited from possessing receiving or transporting a firearm or ammunition which has been shipped or transported in interstate or foreign commerce for the duration of the Order 18 USC sect 922(g) 4 A person commits the offense of Aggravated Stalking when such person in violation of a temporary or permanent protective Order prohibiting this behavior follows places under surveillance or contacts another person on public or private property for the purpose of harassing and intimidating the other person This activity can subject the Respondent to arrest and prosecution for felony Aggravated Stalking which carries penalties of imprisonment for not less than 1 year nor more than 10 years and a fine of up to $1000000

6

--

-----

----------------------------

-----------------------------

--------

business CIVIL ACTION FILE NO ________

19 (Respondent)(petitioner)(both Respondent and Petitioner) [strike through appropriate] isare ordered not to disconnect or have disconnected home utilities change or have changed andor cancel or have canceled auto health or life insurance for Respondent Petitioner andor Petitioners children or interfere with Respondent Petitioners andor Petitioners childrens mail

__ 20 Petitioner shall have sole exclusive temporary possession of the vehicle Make Model Year Color Respondent shall immediately surrender all keys proof of insurance and registration to this vehicle to law enforcement and law enforcement shall immediately tum over said items to Petitioner

__ 21 Petitioner shall be allowed to remove the following property from the family residence for Petitioner andor Petitioners childrens use

On 20 at and law enforcement ___________ (sheriff or police department) is hereby ordered to assist the Petitioner during this removaL

22 Respondent is ordered to undergo alcohoVdrug abuse evaluation and follow the recommended treatment

__ 23 That Respondent shall be required to return the following property for Petitioner andor Petitioners childrens use

On 20 at __m and law enforcement ________ (sheriff or police department) is hereby ordered to assist the Petitioner during this return

24 Petitioner is awarded costs and attorney fees in the amount of

25 FAMILY VIOLENCE INTERVENTION PROGRAM

It is further Ordered that the Respondent shall make arrangements to begin a certified family violence intervention program (FVIP) within fourteen (14) days ofthe signing ofthis Order or if appropriate within fourteen (14) days upon release from incarceration A list of local certified agencies will be given to the Respondent with this Order Furthermore Respondent shall appear before this court __________---____- 20 at m for a hearing on the status ofhislher application attendance andor completion of the FVIP At that hearing Respondent is ordered to present to this court a written status report from the agency providing the certified FVIP The status report shall detail Respondents application attendance andor completion of or failure to apply attend andor complete the FVIP and shall be signed by an officer of the agency

4

---

OR CNIL ACTION FILE NO ________

OR

Respondent is ordered to undergo a certified family violence intervention program and comply with the attached compliance form

Respondent is ordered to undergo a certified family violence intervention program

OR

Respondent is not ordered to undergo a certified family violence intervention program and the following reasons exist

26 Petitionerprotected party is either a spouse former spouse parent of a common (pea07] child Petitioners child child of Respondent cohabitates or has cohabited with

Respondent and qualifies for 18 USC sect 922(g) It is further ordered that the Respondent shall not possess or purchase a firearm or ammunition as restricted by federal law under 18 USC sect 922(g)(8)

27 It is further Ordered

[peaOS]

SO ORDERED this day _________________20__ __

JUDGE SUPERIOR COURT

__________ County

Print or stamp Judges name

Violation of the above Order may be punishable by arrest

5

CIVIL ACTION FILE NO _______

NOTICE TO RESPONDENT

1 Violation of this Order may result in immediate arrest and criminal prosecution that may result in jail time andor fines andor may subject you to prosecution and penalties for contempt of court 2 This Order shall remain in effect unless specifically superceded by a subsequent Order signed and filed by operation of law or by Order of dismissal whichever occurs first Only this Court can void modify or dismiss this Order Either party may ask this Court to change or dismiss this Order 3 If after a hearing of which the Respondent received notice and opportunity to participate a protective order is issued which restrains Respondent from harassing stalking or threatening an intimate partner Respondent is prohibited from possessing receiving or transporting a firearm or ammunition which has been shipped or transported in interstate or foreign commerce for the duration of the Order 18 USC sect 922(g) 4 A person commits the offense of Aggravated Stalking when such person in violation of a temporary or permanent protective Order prohibiting this behavior follows places under surveillance or contacts another person on public or private property for the purpose of harassing and intimidating the other person This activity can subject the Respondent to arrest and prosecution for felony Aggravated Stalking which carries penalties of imprisonment for not less than 1 year nor more than 10 years and a fine of up to $1000000

6

---

OR CNIL ACTION FILE NO ________

OR

Respondent is ordered to undergo a certified family violence intervention program and comply with the attached compliance form

Respondent is ordered to undergo a certified family violence intervention program

OR

Respondent is not ordered to undergo a certified family violence intervention program and the following reasons exist

26 Petitionerprotected party is either a spouse former spouse parent of a common (pea07] child Petitioners child child of Respondent cohabitates or has cohabited with

Respondent and qualifies for 18 USC sect 922(g) It is further ordered that the Respondent shall not possess or purchase a firearm or ammunition as restricted by federal law under 18 USC sect 922(g)(8)

27 It is further Ordered

[peaOS]

SO ORDERED this day _________________20__ __

JUDGE SUPERIOR COURT

__________ County

Print or stamp Judges name

Violation of the above Order may be punishable by arrest

5

CIVIL ACTION FILE NO _______

NOTICE TO RESPONDENT

1 Violation of this Order may result in immediate arrest and criminal prosecution that may result in jail time andor fines andor may subject you to prosecution and penalties for contempt of court 2 This Order shall remain in effect unless specifically superceded by a subsequent Order signed and filed by operation of law or by Order of dismissal whichever occurs first Only this Court can void modify or dismiss this Order Either party may ask this Court to change or dismiss this Order 3 If after a hearing of which the Respondent received notice and opportunity to participate a protective order is issued which restrains Respondent from harassing stalking or threatening an intimate partner Respondent is prohibited from possessing receiving or transporting a firearm or ammunition which has been shipped or transported in interstate or foreign commerce for the duration of the Order 18 USC sect 922(g) 4 A person commits the offense of Aggravated Stalking when such person in violation of a temporary or permanent protective Order prohibiting this behavior follows places under surveillance or contacts another person on public or private property for the purpose of harassing and intimidating the other person This activity can subject the Respondent to arrest and prosecution for felony Aggravated Stalking which carries penalties of imprisonment for not less than 1 year nor more than 10 years and a fine of up to $1000000

6

CIVIL ACTION FILE NO _______

NOTICE TO RESPONDENT

1 Violation of this Order may result in immediate arrest and criminal prosecution that may result in jail time andor fines andor may subject you to prosecution and penalties for contempt of court 2 This Order shall remain in effect unless specifically superceded by a subsequent Order signed and filed by operation of law or by Order of dismissal whichever occurs first Only this Court can void modify or dismiss this Order Either party may ask this Court to change or dismiss this Order 3 If after a hearing of which the Respondent received notice and opportunity to participate a protective order is issued which restrains Respondent from harassing stalking or threatening an intimate partner Respondent is prohibited from possessing receiving or transporting a firearm or ammunition which has been shipped or transported in interstate or foreign commerce for the duration of the Order 18 USC sect 922(g) 4 A person commits the offense of Aggravated Stalking when such person in violation of a temporary or permanent protective Order prohibiting this behavior follows places under surveillance or contacts another person on public or private property for the purpose of harassing and intimidating the other person This activity can subject the Respondent to arrest and prosecution for felony Aggravated Stalking which carries penalties of imprisonment for not less than 1 year nor more than 10 years and a fine of up to $1000000

6

---------------------------

-------------------------

CIVIL ACTION FILE NO ________

Pursuant to OCOA sect 19-13-3 Petitioner assisted by Name

Address

Telephone _______________________

Note to Judges This form is promulgated as a Uniform Superior Court Rule under the auspices of OCOA sect 19-13-53 To order a specific provision please initial in the space provided The court should delete or otherwise make inoperative any provision in the standardized form which is not supported by the evidence in the case and in order to comply with the courts application of the law and facts to an individual case

7

ORI 057

THE SUPERIOR COURT FOR THE COUNTY OF Floylt-d___

STATE OF GEORGIA

]

Petitioner ] ] Civil Action File

v ] ] ] No________

Respondent ] ]

ORDER FOR CONTINUANCE OF HEARING AND EX PARTE PROTECTIVE ORDER

IT IS ORDERED that the hearing for a Protective Order in the above styled case be

continued and rescheduled to _~_________ 20 __

IT IS FURTHER ORDERED that the Ex Parte Protective Order issued on

_______ 20__ in the above styled case is continued until the hearing date of

_______ 20 __ and all provisions of the Parte Protective Order shall remain

in full effect with the following modifications ___________________

This __ day of _______ 20 __

ruDGE SUPERIOR COURT ----- - -----------middot-----------middotmiddot~---middot___ _middotIAI

Print or stamp Judges name

o TRANSMITTED TO GEORGlA PROTECTIVE ORDER REGISTRY DATE CLERK Revd lllOI03

-------

--- ----

OR Number 057

THE SUPERIOR COURT FOR THE COUNTY OF__F_lo~y_d___

STATE OF GEORGIA

Petitioner Civil Action File v

Respondent

DISMISSAL OF TEMPORARY PROTECTIVE ORDER

IT IS HEREBY ORDERED ADJUDGED and DECREED that the (Petition)(CountershyPetition)(Both Petition and Counter-Petition) [strike through appropriate] for TempOral)

Protective Order filed on the __ day 20__ is hereby dismissed without prejudice

[ ] on (petitioners)(Respondents)(Both Petitioners and Respondents) motion to dismiss [ ] on (petitioners)(Respondents)(Both Petitioners and Respondents) failure to appear

and proceed [ ] on (Petitionel)s)(Respondents)(Both Petitioners and Respondents) failme to prove by

a preponderance ofthe evidence the allegations contained in the (petition)(CountershyPetition)(Both Petition and Counter-Petition) for Temporal Protective Order

[ ] due to lack of service on (petitioner)(Respondent)(Both Petitioner and Respondent) [ ] OTHER ___________________

This __ day of________ 20__

JUDGE SUPERIOR COURT Floyd County

-Printor-stampJudges-name-middot-- -- -shy

o Transmitted to Georgia Protective Order Registry Date Clerk

j(~d 225()5

CIVIL ACTION FILE NO ________

REMOVE THIS PAGE FROM ORDER AND FILE SEPARATELY UNDER SEAL

CONFIDENTIAL INFORMATION FORMmiddot ATTENTION COURT STAFF THIS PAGE IS A RESTRICTEDmiddotACCESS DOCUMENT This document is not accessible to the public or to other parties

For transmittal to the Georgia Protective Order Registry and if applicable

the National Crime Information Center

RESPONDENTS IDENTIFYING FACT SHEET (please complete as much as possible one of these must be provided to have the order placed in the National Crime

Information Center registry Respondents date of birth OR social security number)

Respondents social security number is _______ date ofbirth is ____ sex __ color

ofhair ____ color of eyes _____--- height weight __ Respondents

race is _____ ethnic background Respondent has distinguishing marks (tattoos

scars etc) _________ Respondent drives a ____________ license tag

nO_____(Expires~ and has a __(state) drivers license no (Expires~

Respondents home address _---__________________ and is employed

by________ at _______________ and works from to on

(days) Respondent has the following known aliases ____________

PROTECTED PARTIES IDENTIFYING INFORMATION

Petitioner DOB sex race

Other DOB sex race

Other DOB sex race

Other DOB sexmiddot race

Other DOB sex race

D Transmitted to Georgia Protective Order Registry Date ____ Clerk __________

Revd 814

8

---

I

ORI 057

THE SUPERIOR COURT FOR THE COUNTY OF_Flo--Y--d___

STATE OF GEORGIA

] ]

Petitioner ] Civil Action File v ]

] ] ]

Respondent ]

ORDER TO MODIFY PRIOR PROTECTIVE ORDER

IT IS HEREBY ORDERED ADJUDGED and DECREED that the prior Family Violence

Protective Order issued 20 is modified as follows

the remaining parts of the Protective Order issued ________ 20__ remains

unmodified and in full effect

This day ______20

JUDGE SUPERIOR COURT Floyd County

Print or stamp Judges name

o TRANSMIITED TO GEORGIA PROTECTIVE ORDER REGISTRY DATE CLERK

Revd 1110103

ORI 057

THE SUPERIOR COURT FOR THE COUNTY OF Floylt-d___

STATE OF GEORGIA

]

Petitioner ] ] Civil Action File

v ] ] ] No________

Respondent ] ]

ORDER FOR CONTINUANCE OF HEARING AND EX PARTE PROTECTIVE ORDER

IT IS ORDERED that the hearing for a Protective Order in the above styled case be

continued and rescheduled to _~_________ 20 __

IT IS FURTHER ORDERED that the Ex Parte Protective Order issued on

_______ 20__ in the above styled case is continued until the hearing date of

_______ 20 __ and all provisions of the Parte Protective Order shall remain

in full effect with the following modifications ___________________

This __ day of _______ 20 __

ruDGE SUPERIOR COURT ----- - -----------middot-----------middotmiddot~---middot___ _middotIAI

Print or stamp Judges name

o TRANSMITTED TO GEORGlA PROTECTIVE ORDER REGISTRY DATE CLERK Revd lllOI03

-------

--- ----

OR Number 057

THE SUPERIOR COURT FOR THE COUNTY OF__F_lo~y_d___

STATE OF GEORGIA

Petitioner Civil Action File v

Respondent

DISMISSAL OF TEMPORARY PROTECTIVE ORDER

IT IS HEREBY ORDERED ADJUDGED and DECREED that the (Petition)(CountershyPetition)(Both Petition and Counter-Petition) [strike through appropriate] for TempOral)

Protective Order filed on the __ day 20__ is hereby dismissed without prejudice

[ ] on (petitioners)(Respondents)(Both Petitioners and Respondents) motion to dismiss [ ] on (petitioners)(Respondents)(Both Petitioners and Respondents) failure to appear

and proceed [ ] on (Petitionel)s)(Respondents)(Both Petitioners and Respondents) failme to prove by

a preponderance ofthe evidence the allegations contained in the (petition)(CountershyPetition)(Both Petition and Counter-Petition) for Temporal Protective Order

[ ] due to lack of service on (petitioner)(Respondent)(Both Petitioner and Respondent) [ ] OTHER ___________________

This __ day of________ 20__

JUDGE SUPERIOR COURT Floyd County

-Printor-stampJudges-name-middot-- -- -shy

o Transmitted to Georgia Protective Order Registry Date Clerk

j(~d 225()5

CIVIL ACTION FILE NO ________

REMOVE THIS PAGE FROM ORDER AND FILE SEPARATELY UNDER SEAL

CONFIDENTIAL INFORMATION FORMmiddot ATTENTION COURT STAFF THIS PAGE IS A RESTRICTEDmiddotACCESS DOCUMENT This document is not accessible to the public or to other parties

For transmittal to the Georgia Protective Order Registry and if applicable

the National Crime Information Center

RESPONDENTS IDENTIFYING FACT SHEET (please complete as much as possible one of these must be provided to have the order placed in the National Crime

Information Center registry Respondents date of birth OR social security number)

Respondents social security number is _______ date ofbirth is ____ sex __ color

ofhair ____ color of eyes _____--- height weight __ Respondents

race is _____ ethnic background Respondent has distinguishing marks (tattoos

scars etc) _________ Respondent drives a ____________ license tag

nO_____(Expires~ and has a __(state) drivers license no (Expires~

Respondents home address _---__________________ and is employed

by________ at _______________ and works from to on

(days) Respondent has the following known aliases ____________

PROTECTED PARTIES IDENTIFYING INFORMATION

Petitioner DOB sex race

Other DOB sex race

Other DOB sex race

Other DOB sexmiddot race

Other DOB sex race

D Transmitted to Georgia Protective Order Registry Date ____ Clerk __________

Revd 814

8

---

I

ORI 057

THE SUPERIOR COURT FOR THE COUNTY OF_Flo--Y--d___

STATE OF GEORGIA

] ]

Petitioner ] Civil Action File v ]

] ] ]

Respondent ]

ORDER TO MODIFY PRIOR PROTECTIVE ORDER

IT IS HEREBY ORDERED ADJUDGED and DECREED that the prior Family Violence

Protective Order issued 20 is modified as follows

the remaining parts of the Protective Order issued ________ 20__ remains

unmodified and in full effect

This day ______20

JUDGE SUPERIOR COURT Floyd County

Print or stamp Judges name

o TRANSMIITED TO GEORGIA PROTECTIVE ORDER REGISTRY DATE CLERK

Revd 1110103

-------

--- ----

OR Number 057

THE SUPERIOR COURT FOR THE COUNTY OF__F_lo~y_d___

STATE OF GEORGIA

Petitioner Civil Action File v

Respondent

DISMISSAL OF TEMPORARY PROTECTIVE ORDER

IT IS HEREBY ORDERED ADJUDGED and DECREED that the (Petition)(CountershyPetition)(Both Petition and Counter-Petition) [strike through appropriate] for TempOral)

Protective Order filed on the __ day 20__ is hereby dismissed without prejudice

[ ] on (petitioners)(Respondents)(Both Petitioners and Respondents) motion to dismiss [ ] on (petitioners)(Respondents)(Both Petitioners and Respondents) failure to appear

and proceed [ ] on (Petitionel)s)(Respondents)(Both Petitioners and Respondents) failme to prove by

a preponderance ofthe evidence the allegations contained in the (petition)(CountershyPetition)(Both Petition and Counter-Petition) for Temporal Protective Order

[ ] due to lack of service on (petitioner)(Respondent)(Both Petitioner and Respondent) [ ] OTHER ___________________

This __ day of________ 20__

JUDGE SUPERIOR COURT Floyd County

-Printor-stampJudges-name-middot-- -- -shy

o Transmitted to Georgia Protective Order Registry Date Clerk

j(~d 225()5

CIVIL ACTION FILE NO ________

REMOVE THIS PAGE FROM ORDER AND FILE SEPARATELY UNDER SEAL

CONFIDENTIAL INFORMATION FORMmiddot ATTENTION COURT STAFF THIS PAGE IS A RESTRICTEDmiddotACCESS DOCUMENT This document is not accessible to the public or to other parties

For transmittal to the Georgia Protective Order Registry and if applicable

the National Crime Information Center

RESPONDENTS IDENTIFYING FACT SHEET (please complete as much as possible one of these must be provided to have the order placed in the National Crime

Information Center registry Respondents date of birth OR social security number)

Respondents social security number is _______ date ofbirth is ____ sex __ color

ofhair ____ color of eyes _____--- height weight __ Respondents

race is _____ ethnic background Respondent has distinguishing marks (tattoos

scars etc) _________ Respondent drives a ____________ license tag

nO_____(Expires~ and has a __(state) drivers license no (Expires~

Respondents home address _---__________________ and is employed

by________ at _______________ and works from to on

(days) Respondent has the following known aliases ____________

PROTECTED PARTIES IDENTIFYING INFORMATION

Petitioner DOB sex race

Other DOB sex race

Other DOB sex race

Other DOB sexmiddot race

Other DOB sex race

D Transmitted to Georgia Protective Order Registry Date ____ Clerk __________

Revd 814

8

---

I

ORI 057

THE SUPERIOR COURT FOR THE COUNTY OF_Flo--Y--d___

STATE OF GEORGIA

] ]

Petitioner ] Civil Action File v ]

] ] ]

Respondent ]

ORDER TO MODIFY PRIOR PROTECTIVE ORDER

IT IS HEREBY ORDERED ADJUDGED and DECREED that the prior Family Violence

Protective Order issued 20 is modified as follows

the remaining parts of the Protective Order issued ________ 20__ remains

unmodified and in full effect

This day ______20

JUDGE SUPERIOR COURT Floyd County

Print or stamp Judges name

o TRANSMIITED TO GEORGIA PROTECTIVE ORDER REGISTRY DATE CLERK

Revd 1110103

CIVIL ACTION FILE NO ________

REMOVE THIS PAGE FROM ORDER AND FILE SEPARATELY UNDER SEAL

CONFIDENTIAL INFORMATION FORMmiddot ATTENTION COURT STAFF THIS PAGE IS A RESTRICTEDmiddotACCESS DOCUMENT This document is not accessible to the public or to other parties

For transmittal to the Georgia Protective Order Registry and if applicable

the National Crime Information Center

RESPONDENTS IDENTIFYING FACT SHEET (please complete as much as possible one of these must be provided to have the order placed in the National Crime

Information Center registry Respondents date of birth OR social security number)

Respondents social security number is _______ date ofbirth is ____ sex __ color

ofhair ____ color of eyes _____--- height weight __ Respondents

race is _____ ethnic background Respondent has distinguishing marks (tattoos

scars etc) _________ Respondent drives a ____________ license tag

nO_____(Expires~ and has a __(state) drivers license no (Expires~

Respondents home address _---__________________ and is employed

by________ at _______________ and works from to on

(days) Respondent has the following known aliases ____________

PROTECTED PARTIES IDENTIFYING INFORMATION

Petitioner DOB sex race

Other DOB sex race

Other DOB sex race

Other DOB sexmiddot race

Other DOB sex race

D Transmitted to Georgia Protective Order Registry Date ____ Clerk __________

Revd 814

8

---

I

ORI 057

THE SUPERIOR COURT FOR THE COUNTY OF_Flo--Y--d___

STATE OF GEORGIA

] ]

Petitioner ] Civil Action File v ]

] ] ]

Respondent ]

ORDER TO MODIFY PRIOR PROTECTIVE ORDER

IT IS HEREBY ORDERED ADJUDGED and DECREED that the prior Family Violence

Protective Order issued 20 is modified as follows

the remaining parts of the Protective Order issued ________ 20__ remains

unmodified and in full effect

This day ______20

JUDGE SUPERIOR COURT Floyd County

Print or stamp Judges name

o TRANSMIITED TO GEORGIA PROTECTIVE ORDER REGISTRY DATE CLERK

Revd 1110103

---

I

ORI 057

THE SUPERIOR COURT FOR THE COUNTY OF_Flo--Y--d___

STATE OF GEORGIA

] ]

Petitioner ] Civil Action File v ]

] ] ]

Respondent ]

ORDER TO MODIFY PRIOR PROTECTIVE ORDER

IT IS HEREBY ORDERED ADJUDGED and DECREED that the prior Family Violence

Protective Order issued 20 is modified as follows

the remaining parts of the Protective Order issued ________ 20__ remains

unmodified and in full effect

This day ______20

JUDGE SUPERIOR COURT Floyd County

Print or stamp Judges name

o TRANSMIITED TO GEORGIA PROTECTIVE ORDER REGISTRY DATE CLERK

Revd 1110103