THIS IS A WORKSHEET ONLY. YOU WILL HAVE TO COMPLETE A FORM SIMILAR TO THIS AT THE COURT WHERE YOU APPLY FOR YOUR ORDER/INJUNCTION

 

DIRECTIONS: Use this as a worksheet to have the necessary information when you fill out the actual form at the Justice/Municipal/Superior Court in your jurisdiction.

 

Worksheet for Orders of Protection/Injunctions Against Harassment for Arizona Courts

___________________________ Plaintiff / Plaintiff Employer (Work Injunction ONLY)   Birth Date: __________________   Agent's Name:________________ (Work Injunction ONLY)

___________________________ Defendant   _________________________ Address   _________________________ City, State, Zip Code, Phone

Case No.______ PETITION for [ ] Order of Protection [ ] Injunction Against Harassment [ ] Workplace Injunction

 

 

1. Defendant/Plaintiff Relationship: [ ] Married now or in the past [ ] Live together now/lived together in the past [ ] Child in common [ ] One of us pregnant by the other [ ] Related (Parent, In-law, Brother, Sister or Grandparent) [ ] Dating-never lived together

[ ] Other: ______________________________________________________________

 

2. [ ] If checked, there is a pending action involving maternity, paternity, annulment, legal separation, dissolution, custody, parenting time or support in _________ County, Superior Court, Case #:______________

 

3. Have you or the Defendant been charged or arrested for domestic violence OR requested a Protective Order? [ ] Yes [ ] No [ ] Not sure

If yes or not sure, explain________________________________________

 

4. I need a Court Order because: (PRINT both the date(s) and briefly what happened):

 

Date(s)        Describe what happened (Attach additional paper if necessary - Do not
                       write on back)

 

5. The following persons should also be on this Order. As stated in number 4, the Defendant is a danger to them:

______________________(___/___/_____) ____________________ (___/___/_____)
                                                Birth Date                                                    Birth Date

 

______________________(___/___/_____) ____________________ (___/___/_____)

                                                Birth Date                                                    Birth Date

 

6. Defendant should be ordered to stay away from these locations, at all times, even when I am not present:

 

[ ] Home __________________________________________________________

 

[ ] Work __________________________________________________________

 

[ ] School/Others ___________________________________________________

 

7. [ ] If checked, because of the risk of harm, order the defendant NOT to possess firearms or ammunition.

 

8. [ ] If checked, request an order for the Defendant to participate in domestic violence counseling or other counseling.

 

9. Other Requests: ___________________________________________________

 

THIS IS A WORKSHEET ONLY. YOU WILL HAVE TO COMPLETE A FORM SIMILAR TO THIS AT THE COURT WHERE YOU APPLY FOR YOUR ORDER/INJUNCTION.