Request Restraining OrderCal. Super. - 6th Dist.January 28, 2021CH 100 . Request for Civil Harassment Clerkstmatehere Whenfomsflm ___-. Restraininq Orders g LL: E Read Can a Civil Harassment Restraining Order Help Me? (form CH-IOO- INFO) before completing this form. Also fill out Confidential CLETS JAN 23 2021 Informalion Ubrm CLETS-OOJ) with as much informatipn as you know. Supedcgéoerk 0f the Co _ _ U" 0f CA ounty {s® Person Seeking Protection BY o ngci’D'aU’j‘W a. Your Full Name: ’ .53 Q1 OS Oflég Ageefi 09/V Your Lawyer (Ifyou have onefor (his case) Filiin court name and street address: 47 Name: Self-Bepteselfled State Bar No.:_ . gupeEiorcclourt of California, County of . _ _ an a araan Name. Self Represented 191 N First Street b. Your Address (Ifyou have a lawyer, give your lawyer’s 191 N. First Street . . . San Jose, CA 95113 mformatxon. [fyou d0 not have a lawyel and wan! to keep your Civil Courthouse_ DTS home address private you may give a dszerenl mailing address instead. You (1%;10! have to give telepho 2egafmnéggl Court filis in case number when form :‘s filed. Addre : 63 I G?TnEeHflgga7 2 I City: ~ Statezaax 5139.313; u Q u) Telephone: Fax: E-Mail Address: ® Person From \(thomuProtection Is Sought Full Name: LbHMQ/Q) Age:fig Address(fknm )- ”[7083 Uim JAAQQMV City: mgm State:D\- Zip:q§’% ® Additional Protected Persons a. Are you asking for protection for any other family or household members? DYes ENG Ifyes, 11's! them Full Name _S_6§ Ag; Lives with you? How are theV related to you? D Yes D N0 D Yes D N0 D Yes D N0 D Yes D No D Check here ifrhere are more persons. Artach a sheet ofpaper and m‘ite "Attachment 3aiAddiri0nal Protected Persons "for a title. You may useform MC-025, Attaclmzem. b. Why do these peeple need protection? (Explain below): yD Check here iffhere is not enough spacefor your answer. Pm‘ your complete answer on the attached sheet 0f paper orfiarm MC-025 cmd write “Alrachmenr 3b-Why Others Need Protection "for a title. This is not a Court Order. éflfia‘ifififi'fi’CzaéligT'aan‘E‘éfiéfiégfin“ 9°“ Request for Civil Harassment Restraining Orders CH-1oo, Page 1 ore Coda owail Procedure §§ 527.63nd 527.9 - - . .Essenfial (CIVII Harassment Prevention) ROHCI [1 PVERN9 cehcorn z Case Number: ® Relationship of Parties How do you know théfperson in ®‘? (Explain below): Check here iflhere 1's nor enough spacefor your answer. Put your complete answer 0n (he attached sheet 0f papa orform JWC-O25 and wrife ‘Mrrachmem 4-Relationslzip ofParties "for a rifle. © Venue Why are you filing in this county? (Check all that apply): aE The person in® lives in this county b a I was harassed by the person in® 1n this coun c. E Other (specifiz). ’f/ IA-ExQ WNWMg \OU 0,6650“ \/\ CO ® Other Court Cases _ a. Have you 0r any 0fthe persons named in® been involved in another court case with the person in (2)? D Yes aNo (Ifyes, check each kind ofcase and indicate where and when each wasfiled.) I Kind 0f Case ‘ Filed in (Counrv/State) Year Filed Case Numberjifknown) (UVD Civil Harassment (2) D Domestic Violence . (3) D Divorce,Nullity, Legal Separation (4) D Paternity, Parentage, Child Custody (5) D Elder 0r Dependent Adult Abuse (6) D Eviction (7) D Guardianship (8) D Workplace Violence (9) D Small Claims (10)D Criminal (1DD Other (specify): b. Are there now any protective or restraining orders in effect relating to you or any of the persons in @and the person in®? QNO DYes (Eyes, attach a copy ifyozt have one.) ® Description of Harassment Harassment means violence 0r threats 0f violence against you, 0r a course 0f conduct that seriously alarmed, annoyed, 0r harassed you and caused you substantial emotional distress. A course of conduct is more than one act. a. Tell the court about the last time the person in @harassed you. l/ /(1) When did it happen? @rovide dale 0r estimated date): / ,Q / 2 W1 l th 9( ) 10 e se was ere [See attached declaration for a Description of Harrassmefi] (MM)? JaimeW M: 0m J14, JACK This is not a Gourt Order. Remmmm‘ 2°” Request for Civil Harassment Restraining Orders CH-1oo, Page 2 ofs EBiEssenua' (Civil Harassment Prevention) _ 9mbmm Case Number: ® a. (3) How didthe personin®harass you? (Explain below):D Check here ifthere is nor enough spacefor your answer. Put your complete answer 0n the fittached sheet 0 a e) 0r form MC-025 and write 'Attachment 7a(3)-Describe Hams men "f0; aritle. (Saim lama 401W o r AOMQLJE/F WQKKTM ”(MW% (Md (2mm 41:) mq WW3? . hmfié’fi WM laan/wr mil? 9/ no, 1m WOLWMQI ’YU, IMHA M Qfl‘bfiém uJQ/(‘P hmflM m ml/f \L mhflm). Wm Wf oxOpAeA méqéquchkaO H'LlJWS ma» wamk- imA 5 WWc-t m ainthW (logfihv 7mm oq‘CmAu dCuWS mmf’rl muW {erélam l, --’7rW (4) Did the pelrson m® use or threaten t0 use a gIJ‘n 0r any other weapon? D Yes? N0 (Ifyes, explain below). hD Che k ere fifthere i3 not enough spaceforyour answer. Put your complete answer 0n the attached sheet ofpaper 0rf0rm MC-025 and write “Attachment 7a(4)-Use 0fWeap0ns”f0r a title. (5) Were you harmed or injured because 0f the harassment? EYes D No (Ifyes, explain below): Check here {ftlzere is not enough spacefor your answer Put your complete answer 0n the attached sheet ofpaper 0rform MC-025 and write "Attachment 7a(5)-Haml 0: Injury' ’fOI a title Mu ADS? macs th+ 00m Om m IMRHA QLS‘CWQ M chb (6) Did the police come? ?Yes DNO lfyes, did they give yo or the person in @an Emergency Protective Order?D YesENo If yes, the order protects (check all that apply): DMe D The person in ® D The persons in @. (Attach a copy offhe order ifyou have one.) b. Has the person in ® harassed you at other times?a Yes BNO (Ifyes, describe prior incidents cmdprovz'de dares ofharassment below): a Check here ifthere is not enough spacefor your answer. Put your complete answer 0n (he armched sheet 0f paper orform MC-025 and write "Aflachmen! 7b-Prevz'0us Harassment "for a title. This is not a Court Order. ' Revised January 1, 201.3 I Request for Civil Harassment Restraining Orders CH-1oo, Page 3 ore EB’ESSQMW (Civil Harassment Prevention) ahmm mm 9 Case Number: Check the orders you want. E Q Personal Conduct Orders l ask the court to order the person in ®not to d0 any ofthe following things to me or to any person to be protected listed in©: a. E Harass, intimidate, molest, attack, strike, stalk, threaten, assault (sexually or otherwise), hit, abuse, destroy personal property of, or disturb the peace of the person. b. BContact the person, either directly 0r indirectly, in any way, including, but not limited to, in person, by telephone, in writing, by public or private mail, by interoffice mail, by e-mail, by text message, by fax, or by other electronic means. c. flower (specifii): . D Check here tfthere is nor enough spacefor your answer. Put your complete answer on the attached sheer ofpaper orform MC-025 and write Mttachmem 8c-Other Personal Conduct Orders, ”for a title. E L ’ ' The person in ®wili be ordered nor to take any action t0 get the addresses or locations ofany protectedperson unless the cozn‘rflnds good cause n0! f0 make Ihe Order. ® EStay-Away Orders a. I ask the court to order the person in ® t0 stay at leastLa yards away from (check all that apply): (Um Me. (8) D My vehicle. (2) D The other persons listed in®. (9) D Other (specify): (3) E My home. (4) D Myjob or workplace. (5) a My school. (6) D My children’s school. (7) D My children’s place 0f child care. b. Ifthe court orders the person in ®to stay away from all the places listed above, will he or she still be able to get to his 0r her home, school, orjob? E Yes DNO (Ifno, explain below): D Check here ifthere is not enough spacefor your answer. Pm your complete answer 0n the atlached sheet of paper orform MC-025 and write “Attachment 9b-Slay-Away Orders, "for a (itle. Guns or Other Firearms and Ammunition Does the person in @own or possess any guns or other firearms? DYes DNO W don’t know [frhejudge grants a protective order, the person in ® will be prolzibitedfrom owning, possessing, purchasing, receiving, 0r attempting f0 purchase 0r receive a gun, otherfirearm, and ammunition while the protective order is in effect. The person in ®will also be ordered to [urn in to law enforcement, or sell t0 0r store with a licensed gzm dealer, any guns orfirearms within his 0r her immediate possession 0r control. This is not a Court Order. EvgJagjsWegigf Request for Ciyi'l Harassment Restraining Orders CH-1oo, Page4 ore “Mm Efimy (le Harassment Prevention) 9 Case Number: ® Q Temporary Restraining Order I request that a Temporary Restraining Order (TRO) be issued against the person in ® t0 last u_ntil t_he hearing. I am presenting fom1 CH-l 1 0, Temporary Restraining Order, for the court’s signature together w1th thls Request. Has the person in ® been told that you were going to go t0 court t0 seek a TRO against him/her? EYes a N0 (Ifyou answered n0, explain why below): D Check here I'fthere is nor enough spacefor your answer: Put your complete answer 0n the attached sheet 0f paper orform fi/IC-025 and write "Attachment I I-Temporalj} Restraining Order "for a tille. ® D Request to Give Less Than Five Days‘ Notice of Hearing You mus! have your papers personally served 0n the person in ® at leaslfive days before t/ze hearing, unless the court orders a shorter (imefor service. (Form CH-ZOO-INFO explains What ls “Proof of Personal Service”? Form CH-200, Proof of Personal Service, may be used t0 show the court that (he papers have been served.) If you want there to be fewer than five days between service and the hearing, explain why below: D Check here ifthere 1's not enough spacefor your answer. Pul your complete answer 0n the attached sheer 0f paper orform MC-025 and write "Attachment JZ-Requesf to Give Less Than Five Days'Notice "for a title. a No Fee for Filing or Service . a.fl There should be no filing fee because the person in®has used or threatened to use violence against me, has stalked me, 0r has acted 0r spoken in some other way that makes me reasonably fear violence. b. a The sheriff or marshal should serve (notify) the person in @about the orders for free because my request for orders is based 0n unlawful violence, a credible threat of violence, 0r stalking. c. .8 There should be no filing fee and the sheriff or marshal should serve the person in ®for free because I am entitled t0 a fee waiver. (You must complete andfilcform FW-OOI, Application for Waiver of Court Fees and Costs.) E Lawyer's Fees and Costs I ask the court to order payment of my a lawyer's fees E Court costs. The amounts requested are:m Amount It_erg Amount Ellingiee- $ 435 $ $ $ $ $ D Check here ifthere are more items. Put the items and amounts 0n rhe attached sheet ofpaper orform MC-025 and write "Attachmenl 14-Lawyer ’s Fees and Costs"f0r a lille. This is not a Court Order. Refe‘iflgmm‘a Request for Civil Harassment Restraining Orders CH-1oo, Page 5 ofs C'iB . sent'a]. (Civil Harassment Prevention) 9cehmm Em . Case Number: D Possession and Protection of Animals I ask the court to order the following: a. DThatI be given the sole possession, care, and control ofthe animals listed below, which I own, possess, lease, keep, or hold, or which reside in my household. (Idermfi/ animals by, e.g., Ij’pe, breed, name, color, sex.) I request sole possession of the animals because (specify good cause for granting order): D Check here ffthere 1‘s nor enough spacefor your answer. Put your complete answer 0n the attached slzee! ofpaper orform MC-025 and write “Armchmem I 5a-Possessi0n ofAnimals "for a title. b. DThat the person in ® must stay at least yards away from, and not take, sell, transfer, encumber, conceal, molest, attack, strike, threaten, harm, or otherwise dispose of, the animals listed above. . DAdditional Orders Requested I ask the court to make the following additional orders (specijfv). D Check he) e iflhere is no! enough spacefoz you)" answer. Pu! your complete answer 0n (he altached sheer 0f paper orform M'C-025 and write “Attachment I 6-Ada’ilional Orders Requested, "for a rifle. ® Number 0f pages attached'to {his form, ifany: Date: SeJLBepmsenmd- -_SeJLBepLesanled--S£lf;BepLesenmd-__ Lawyer 's name (ifany) > Lawyer’s signature I declare under penalty of perjury under the laws ofthe State of California that the information above and on all attachments is true and (meet. Date: 0mm (Zwej Type or prim your name W(%@M% Sign youCname This is not a Court Order. Revised January 1. 2018 . Request for Civil Harassment Restraining Orders CH-1oo, Page 50:6 [Effienfla' (Civil Harassment Prevention)W Q onn3' 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 CASE NAME: Q&M< 3”“ (WWQ CASE #: LasqName U Last Name CH-100, Item 7a(3)- DESCRIBE HARASSMENT. a) How do you know the person you want to restrain?M (’f MU! WW3 F&OKNRXGAA 5W b) Are you living with the person? D YES [ELNO c) Has the person D physically abuse you, D physically or verbally threatened you andlor D harassed you many times? (Please check all that apply.) d) In the past three months, what did the person do or say that made you afraid (please start with the most recent event and eprain exactly what happened in detail, include dates nd ti es): /7 Q} "700W Oxmé OVJVET/mbd NMW NMM Www» Orx vW/nQXv-IA-nPA/VQD MiG MM JD Mx/NI [WWW W- 0AM MMOM 00km, mWfimLmM Hm” (Md Qwéflxe/d ML (WWW! \klnILé/flld“ 4%an 4o [AIL Mflmui «+0 amW8 JO WP L’Aifim 0,004» $A (NMm \OWI'ULMé die W rDmCQ/Omj _ L {faith}W QM OdeM bang??? CH-1oo, Item 7a(3) - DESCRIBE HARASSMENT Page_ 10 11 12 13 14 15 15 17 18 19 20 21 22 23 24 25 CASE NAMEQQHQ? a”? (QMOS CASE #z LailName Last Name e) Were any guns or other weapons used or threatened to be used during any abuse in the past three months? D YES fi No If “YES“, describe: f) Were there any injuries during abuse in the past three months?EYES D NO WES". describe: If [7' 7A g) Did the police come to any of these recent events? HYES D NO h) Did they giVe you an Emergency Protective Order for abuse in the past three months? D YES MO If ”YES”, please attach a copy. i) Is the person you want to restrain in jail right now for violence against you? [:IYES >GNO tf“YE3",where: j) Has the person you want restrained ever been in jail for violence against you or your children? E1 YES yzmo If "YES", when: A Describe what the person did to you or your children that caused them to go to jaii: CH-1 00, Item 78(3) - DESCRIBE HARASSMENT Page_ 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 CASE NAME:mag anflouwg CASE #: Last Name Last Name k) Do you have a criminal protective order (restraining order from criminal court)? EYES [:1 No If “YES", please attach a copy. I) Describe the worst abuse and when it happened: E The most recent abuse i_s the worst abuse OR D The worst abuse was (approximate date) - ( Z/ and the person l want a restraining order against (describe what they did to you): m) Describe any other previous (past) violence or threats of violence that you haven't already written about here (include dates or estimates as to when it happened): CH-1 00, Item 73(3) - DESCRIBE HARASSMENT Page#
