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  • PLEASE READ BEFORE YOU CONTINUE:

    Security of your sensitive information provided in this form is important to us. Therefore, we cannot SAVE your entry to complete at a later time. 

    Please have ALL your information ready to input/upload and allow time to complete this form. (Full Name(s), Documents, Dates, etc.)

  • APPLICATION FOR LEGAL SERVICES

    PROTECTIVE ORDER

     

  • PLEASE ANSWER ALL REQUIRED QUESTIONS IN THIS APPLICATION. THE FOLLOWING INFORMATION IS FOR OUR USE ONLY. WE WILL LET YOU KNOW IF YOUR APPLICATION HAS BEEN ACCEPTED WITHIN FOUR WEEKS.

  • Do you have a pending case in court?
  •  - -
  • Was the case filed by you or your the adverse party?
  •  - -
  • Are you receiving services from Family Violence Prevention Services?
  • Which copies of EVIDENCE do you have? (Check all that apply)
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  • YOUR INFORMATION

  • Do you want your maiden name restored?
  • Is it safe to receive mail at the above address

  • Please provide your contact information below where our agency can reach you.

  •  -
  • Is this Home Phone Number safe?
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  • Is this Work Phone Number safe?
  •  -
  • Is this Cell Phone Number safe?
  • Is this Email Address safe?
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  • YOUR INFORMATION

    CONTINUED

  • Below, please provide some information about yourself. If you do not have a Social Security Number or Driver’s License, please write “N/A” in the appropriate space(s).

  •  - -

  • Please record your citizenship or immigration information below.

  • Are you a U.S. Citizen?
  • Do you have a VISA, Work Pass or Other?

  • Are you a Permanent Resident?
  • Are you Undocumented?
  • Are you currently in the military?
  • Active Duty or Reserves?
  • Are you retired or separated from the military?
  • Were you honorably discharged?
  • Are you employed?

  • ADVERSE PARTY INFORMATION

  • Can the Adverse Party be served at the above address?
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  •  -
  •  -
  • Is the Adverse Party currently in the military?
  • Active Duty or Reserves?
  • Is the Adverse Party retired or separated from the military?
  • Was he/she honorably discharged?
  • Is the Adverse Party a U.S. Citizen?
  • Does The Adverse Party have a mental or physical condition?
  • Did you ever reside with the Adverse Party?
  •  - -

  • INFORMATION ABOUT CHILDREN

  • List all of your minor children, even if they have different parents and even if they are not currently living with you:

  • INFORMATION ABOUT CHILDREN

  • Add Child #2?
  • Add Child #3?
  • Add Child #4?
  • Add Child #5?
  • Add Child #6?
  • Add Child #7?
  • Has anyone from CHILD PROTECTIVE SERVICES ever contacted you?

  • FAMILY VIOLENCE

  •  

    Domestic violence can be defined as a pattern of behavior in any relationship that is used to gain or maintain power and control over an intimate partner. Abuse includes physical, sexual, emotional, economic, and psychological actions or threats of actions that influence another person. Domestic violence may result in emotional trauma and physical injury and may include the abuse of children and other family members, as well as intimate partners.

    To assist our agency in assessing the urgency of your case, please state the nature of the violence that happened to you and/or your children. Give the month, day, and year of each incident and explain what the adverse party did. Please note if there are police reports and give the case numbers, if so. Please include ALL the incidents of violence you experienced, including those that are not very recent and those that did not involve the police. If you do not remember the dates of violence, please write “N/A” in the appropriate space(s). If the violence you experienced occurred over a long time or constantly during your relationship and you cannot recall a specific incident, please record the long term mistreatment and give the frequency with which it happened.

  • Incident Information

  • To assist our agency in assessing the urgency of your case, please state the nature of the violence that happened to you and/or your children. Give the month, day, and year of each incident and explain what the adverse party did. Please note if there are police reports and, if so, give the case numbers. Please include ALL the incidents of violence you experienced, including those that are not very recent and those that did not involve the police. If you do not remember the dates of incidents of violence, please write “N/A” in the appropriate space(s). If the violence you experienced occurred over a long period of time or constantly during your relationship and you cannot recall a specific incident, please record the long term mistreatment and explain the frequency with which it happened.

  • Incident #1

  • Were the police contacted?
  • Would you like to report a 2nd Incident?

  • Incident #2

  • Were the police contacted?
  • Would you like to report a 3rd Incident?

  • Incident #3

  • Were the police contacted?
  • Are all of your minor children living with you?
  • Have you contacted the D.A.’s office (or the Family Justice Center) for a Protective Order?
  • Do you understand that your case may be refused if you do not provide an accurate address for the Adverse Party so that he/she may be served?
  • Have you had a previous Protective Order?
  • Have you ever been to court before for any reason?

  • PROPERTY INFORMATION

    If you or the Adverse Party own any of the following property, please check all that applies:
  • Home

  • Car

  • Retirement Account

  • Savings Account

  • Certificate of Deposit (CD)

  • Thrift Savings Plan

  • Rental Property

  • YOUR FINANCIAL INFORMATION

    The following information will be used to determine financial eligibility and to prepare an affidavit. If we are able to accept your case, you will be required to sign and notarize the affidavit, so that you will not have to pay filing fees. This information MUST be accurate.

  • MONTHLY INCOME

  • If you were referred to our agency, how did you find out about our services?

  • By signing and submitting this form you certify that the information provided herein (this web form) is true and correct to the best of your knowledge.

  • Click the "Submit Form" button only once.

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