Request For Domestic Violence Restraining Order: Name of Person Asking For Protection
Request For Domestic Violence Restraining Order: Name of Person Asking For Protection
Age: 55
Your lawyer in this case (if you have one):
State Bar No.:
Name: In Pro Per
Firm Name:
Address (If you have a lawyer for this case, give your lawyers
information. If you do not have a lawyer and want to keep your home
address private, give a different mailing address instead. You do not
have to give your telephone, fax, or e-mail.):
Address: 40539 Johnston Rd.
City: Cutler
State: CA Zip: 93615
Fax:
Telephone: 559-528-6488
E-Mail Address:
2
TULARE
COUNTY CIVIC CENTER
221 S. MOONEY BLVD.
VISALIA, CA 93291
Clerk fills in case number when form is filed.
Case Number:
Sex:
M F Height: 5ft 8in
Race: Hispanic
Address (if known): Unknown
City:Cutler
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State: CA
Yes
No
Age
Relationship to you
Lives with you?
Yes
No Grandson
Yes
No
Yes
No
Check here if you need more space. Attach a sheet of paper and write DV-100, Protected People for a title.
Justin Gonzalez
Sex
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h.
DV-100, Page 1 of 5
Case Number:
b.
Contact, either directly or indirectly, in any way, including but not limited to, by telephone, mail or
e-mail or other electronic means
The person in 2 will be ordered not to take any action to get the addresses or locations of any protected
person unless the court finds good cause not to make the order.
Stay-Away Order
yards away from (check all that apply):
a. I ask the court to order the person in 2 to stay at least 500
Me
My vehicle
My home
The childrens school or child care
My job or workplace
Each person listed in 3
My school
Other (specify):
b. If the person listed in 2 is ordered to stay away from all the places listed above, will he or she still be able
No (If no, explain):
to get to his or her home, school, job, workplace, school, or vehicle? Yes
Move-Out Order
(If the person in 2 lives with you and you want that person to stay away from your home, you must ask for
this move-out order)
I ask the court to order the person in 2 to move out from and not return to (address):
I have the right to live at the above address because (explain): I own this home and I am the legal
guardian of Dora's son Justin and they are unable to be civil with one another.
This is not a Court Order.
Revised January 2, 2012
DV-100, Page 2 of 5
Case Number:
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Property Control
I ask the court to give only me temporary use, possession, and control of the property listed here:
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Debt Payment
I ask the court to order the person in 2 to make these payments while the order is in effect:
Check here if you need more space. Attach a sheet of paper and write DV-100, Debt Payment for a title.
Due date:
Pay to:
For:
Amount: $
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Property Restraint
I am married to or have a registered domestic partnership with the person in 2 . I ask the judge to order
that the person in 2 not borrow against, sell, hide, or get rid of or destroy any possessions or property, except
in the usual course of business or for necessities of life. I also ask the judge to order the person in 2 to notify
me of any new or big expenses and to explain them to the court.
DV-100, Page 3 of 5
Case Number:
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Spousal Support
I am married to or have a registered domestic partnership with the person in 2 and no spousal support order
exists. I ask the court to order the person in 2 to pay spousal support. (You must fill out, file, and serve Form
FL-150, Income and Expense Declaration, before your hearing).
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For:
Amount: $
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Other Orders
What other orders are you asking for?
Check here if you need more space. Attach a sheet of paper and write DV-100, Other Orders for a title.
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Court Hearing
The court will schedule a hearing on your request. If the judge does not make the orders effective right away
(temporary restraining orders), the judge may still make the orders after the hearing. If the judge does not
make the orders effective right away, you can ask the court to cancel the hearing. Read Form DV-112, Waiver
of Hearing on Denied Request for Temporary Restraining Order for more information.
DV-100, Page 4 of 5
Case Number:
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Describe Abuse
Describe how the person in 2 abused you. Abuse means to intentionally or recklessly cause or attempt to cause
bodily injury to you; or to place you or another person in reasonable fear of imminent serious bodily injury; or to
molest, attack, hit, stalk, threaten, batter, harass, telephone, or contact you; or to disturb your peace; or to destroy
your personal property. Abuse can be spoken, written, or physical. (For a complete definition, see Family Code
6203, 6320).
a. Date of most recent abuse: 4/10/ 2014
b. Who was there? All immediate family members.
c. Describe how the person in 2 abused you or your children: Dora broke into my home and hid in a
bedroom of another family member, and refused to leave when asked. Dora know she is not
wanted nor allowed in my home. When I told her I was calling the police she proceeded to
threaten me and my family members stating that if I called the police she would hurt me and
another member of my family in the home.
Check here if you need more space. Attach a sheet of paper and write DV-100, Recent Abuse for a title.
Yes (If yes, describe):
d. Did the person in 2 use or threaten to use a gun or any other weapon? No
e. Describe any injuries:
f. Did the police come?
No Yes
I dont know
If yes, did they give you or the person in 2 an Emergency Protective Order?
Yes No
Attach a copy if you have one.
The order protects
you or
the person in 2
g. Has the person in 2 abused you (or your children) other times?
If yes,
check here and use Form DV-101, Description of Abuse or a sheet of paper to describe any
previous abuse.
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a prior case that involves physical violence against one another. They are not to be near or
around each other. I, Elodia Uribe, currently have legal guardianship of Justin Gonzalez.
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I declare under penalty of perjury under the laws of the State of California that the information above is true and correct.
Date: 4/27/14
Elodia Uribe
Sign your name
Lawyers signature
DV-100, Page 5 of 5