Request Restraining OrderCal. Super. - 6th Dist.January 28, 2021Request for Civil Harassment A CH'190 Restraining Orders Clerk stamps date here when form is filed. Read ('un u ('iri/ llurus'smcn! Restraining ()rder Help Me? (form ('H-IOO- INFO) before completing this form. Also fill out Confidential ('LETS Information (form (‘LETS-OOI) with as much information as you know. Person Seeking Protection a. Yoyr FullNa mom rxrgmek’a’mve'z Agebe Your Lawyer (t_‘fyou have onefor this case) Name: SelfiRepLesented- State Bar No.:__ Firm Name:Mmmd b. Your Address (Ifyou have a lawyer, give your lawyer 's information. lfyou d0 n0! have a lawyer and wan! (0 keepyour home address private, you may give a diflerem mailing address instead You do n0! have to give telephgne, fax, 0r e-mail.) Address: City: StateflL Zip: Telephone: ' ' ‘ * (v Fax: E-Mail Address: ® Person From Whom Protection Is Soug t ' S me ILED JAN 2 8 2021 Fill in court name and street\address: Superior Court of California, County of Santa Clara 191 N. Fgrst Street 191 N. Flrst Street San Jose, CA 95113 Civil Courthouse - DTS Court fills in case number when form is filed. Case Number: 210H009833 Age:__m NFull Name: r ‘ Address (ifknown): 4-1 ‘ mlflmlMD{ ' CityngA 3-0.5f State: (‘4 Zip: gt;\a:$ ® Additional Protected Persons a. Are you asking for protection for any other family or household members?mes DNO (fives, list them: Full Name Sex Agg M\3L\fl mgk 73-8 Lives with you?m Yes D No andD Yes D No D Yes D No D Yes D No How are they related to you? D Check here ifthere are more persons. Attach a sheet ofpaper and write “Attachment 3a-Additional Protected Persons "for a title. You may useform MC-025. Attachment. b. Why do these people need protection? (Explain below): D Check here iflhere is not enough spacefor your answer. I’m your complete answer 0n the attached sheet 0f pas ’r orform MC-025.and write “Atrachmcm 3b-Why Others Need Protection ”for a title. F \Q \x‘f {1099: (\vxl-C\ “ vl\ Ii . e: |.- n.: t. _1 aw: n. 033m f‘ m... 0; _.. 0 (MW mm mp1 ,_-QE§L2( e g- m u I J This is not a Court Order. flfim°¥°2fi'¥fif”m“m Request for Civil Harassment Restraining Orders (Civil Harassment Prevention) CH-100, Page 1 016 ROHC/ [ ] PVERN9 Case Number: ® Relationship of Parties How do you know the person in ®? (Explain below): D Check here iflhere is n0! enough spacefor your answer. Pu! your compleIe answer 0n the attached sheet 0f paper orform MC-025 and write “Atlachmem 4-Relalionship ofParIies "for a title. ' ' a <9 Venue F(«md . Why are you filing in this county? (Check all that apply): a. The person in ® lives in this county. b/gl was harassed by the erson in® in this county. . c. D Other (specifi): T' I W ® Other Court Cases a. Have you or an of the persons named in® been involved in another court case with the person in@? D Yes Z)No (Ifyes, check each kind ofcase and indicate where and when each wasfiled.) Kind of Case Filed in (Coungy/Statez Year Filed Case Number (ifknown) (l) D Civil Harassment (2) D Domestic Violence (3) D Divorce, Nullity, Legal Separation (4) D Paternity, Parentage, Child Custody (5) D Elder or Dependent Adult Abuse (6) D Eviction (7) D Guardianship (8) D Workplace Violence (9) D Small Claims (IO)D Criminal (l DD Other (specifiz): b. Are there now any protective or restraining orders in effect relating to you or any ofthe persons in ©and the person in®? o DYes (lfyes, attach a copy Ifyou have one.) ® Description of Harassment Harassment means violence or threats of violence against you. or a course of conduct that seriously alamed, annoyed. or 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. (I) When did it happen? (provide date 0r estimated date): \ Im [’2‘ r V h I h ?(2) w o e 5e waSt ere [See attached declaration for a Description of Harrassment] This is not a Court Order. ""WW" ‘- 2°“ Request for Civil Harassment Restraining Orders CH-1oo, page 2 ore OBm (Civil Harassment Prevention) 9 CaseNum?r1 CHOU 98 33 ® a. (3) How did the person in® harass you? (Explain below):D Check here zfthere is n0! enough spacefor your answer. Put your complete answer 0n the attached sheet ofpaper 0rf0rm MC-025 and write “Attachment 7a(3)-Describe Harassment "for a title. (”afiflg knobs gang: mpiuvlj (\QDF' (4) Did the person in® use or threaten to use a gun or any other weapon? mes D No (lfyes, explain below): D Check here ifthere is n0! enough spaceforyour answer. Put your complete answer 0n the attached sheet ofpaper ()rfbrm MC-025 and write “Attachment 7a(4)--Use 0f Weapons"for a title. Md ' flS . ' on ~ ‘ ~ huE (5) Were you harmed or in' red because of the harassment. m\fi K wbm) P \(D Yes N0 (Ifyes, explain below): D Check here ifthere is n0! enough spacefor your answer. Put your complete answer on the attached " “xx 0L N t ?\Q° \M sheet ofpaper orform MC-025 and write "Attachment 7a(5)-Harm or Injury ”for a title. (6) Did the police come? m Yes D No If yes, did they give you or the person in ®an Emergency Protective Order?D Yes M No lf yes, the order protects (check all that apply).- DMe D The person in ® D The persons in @. (Attach a copy ofthe order ifyou have one.) b. Has person in ® harassed you at other times? Yes D No (Ifyes, describe prior incidents andprovide dates ofharassment below): D Check here ifthere is not enough spacefor your answer. Pu! your complete answer on the attached sheet of paper orform MC-025 and write “Attachment 7b-Previ0us Harassment "for a title. ‘Lhme wagsageg Aj/rOM LA This is not a Court Order. ""“JW‘~2°‘° Request for Civil Harassment Restraining Orders CH-1oo, Page soreGB Em (CIVII Harassment Prevention) 9 Case Number: Check the orders you want. m Personal Conduct Orders l ask the court Io order the person in ®not to do any of the following things to me or to any person to be protected listed in® : a. m 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. mContact the person, either directly or 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. D Other (specifiz): D Check here ifthere is not enough spacefor your answer. Put your complete answer on the attached sheet ofpaper orform MC-025 and write "Attachment 8c-Other Personal Conduct Orders, "for a title. __‘_ _ . u _ ' I i The person in ®will be ordered not t0 take any action (0 get the addresses 0r locations ofany prorectedperson unless the courtfinds good cause nor to make the order. G) fiStay-Away Orders a. l ask the urt to order the person in ® to stay atyd; yards away from (check a1! tha! apply): (1) Me. (8) My vehicle. mm». 5M away (2) a The other persons listed in@. (9) Z/Other (specify): (3),Z’My homeuwaonW _ EXa/f/an 5 Ff JV? diva, _(4) a Myjob or workplace. a -' h ‘ ’ ['0 -/ - fl" (We m _ (5) My school. _w ”t w id“L (6) My children’s school. - ‘-’ “ " . ,1 (7) a My children’s place of child care. ' b. If the coun orders the person in ®to stay away from all thé’places listed above, will he or sfie still be able to get to his or her home, school, orjob? D Yes DNO (Ifno. explain below): D Check here ifthere is not enough spacefor your answer. Put your complete answer 0n the attached sheet of paper 0r orm MC-025 and write "Altachment 9b-SIay-Away Orders, "for a title. a < 1’ k ‘\ \vnrx nbk ( b M6 wad ’ Guns or Other Firearms and Ammunition Does the person in ®own or possess any guns or other firearms? DYes DNo Won’t know Iflhejudge granrs a protective order, the person in ® will be prohibitedfrom owning. possessing, purchasing, receiving, or attempn’ng r0 purchase or receive a gun, otherfirearm, and ammunition while the protective order is in eflect. The person in ®will also be ordered Io turn in 10 law enforcement, or sell to 0r store with a licensed gun dealer, any guns orfirearms within his 0r her immediate possession or control. This is not a Court Order. R'“’°‘{“"“""-2°‘° Request for Civil Harassment Restraining Orders cn-1oo, page4ore(m [m (Civil Harassment Prevention) 9 Case Number: 210H009833 ® @Temporary Restraining Order l request that a Temporary Restraining Order (TRO) be issued against the person in ® to last until the hearing. I am presenting fom1 CH-I 10, Temporary Restraining Order, for the court’s signature together with this Request. Has the person in ® been told that you were going to go to court to seek a TRO against him/her? DYes o (Ifyou answered no, explain why below): D Check here ifthere is not enough spacefor your answer. Put your complete answer 0n the attached sheet of paper orform MC-025 and write “Attachment Il-Temporary Restraining Order "for a title. ® D Request to Give Less Than Five Days' Notice of Hearing You mus! have your papers personally served 0n the person in® at leastfive days before the hearing, unless the court orders a shorter time for service. (Form CH-ZOO-INFO explains What ls “Proof of Personal Service”? Form CH-200, Proof of Personal Service, may be used to show the court that the 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 is not enough spacefor your answer. Put your complete answer 0n the attached sheet 0f paper orform MC-025 and write “Attachment 12-Request t0 Give Less Than Five Days’Notice ”for a title. ® No Fee for Filing or Sefvice a. ¥ There should be n0 filing fee because the person in®has used or threatened to use violence against me, has stalked me, or has acted or spoken in some other way that makes me reasonably fear violence. b. The sheriff or marshal should serve (notify) the person in ®about the orders for free because my request for orders is based on unlawful violence, a credible threat of violence, or stalking. c. There should be no filing fee and the sheriff or marshal should serve the person in ®for free because l am entitled to a fee waiver. (You must complete andfileform FW-001, Application for Waiver of Court Fees and Costs.) m Lawyer's Fees and Costs Iask the court to order payment of my D lawyer's fees m Court costs. The amounts requested are:m Amount IKL Amount Emngfle $ 435 s s $ $ $ D Check here ifthere are more items. Pm the items and amounts on the attached sheet ofpaper orform MC-025 and write "Attachment 14-Lcm'ycr ‘s Fees and Costs"fi)r a title. This is not a Court Order. R‘“’°“‘"“"Y "2°” Request for Civil Harassment Restraining Orders CH-1oo, Page sore OB‘JEJWM“ (Civil Harassment Prevention) 9 Case Number: @ D Possession and Protection of Animals I ask the court to order the following: a. D That I be given the sole possession, care, and control of the animals listed below, which l own, possess, lease, keep, or hold, or which reside in my household. (Identtfi animals by, e.g., type, breed, name, color, sex.) I request sole possession of the animals because (specifi/ good causefor granting order): D Check here {fthere is not enough spacefor your answer. Put your complete answer 0n the attached sheet ofpaper orform MC-025 and write "Attachment 15a-Possession ofAm'mals ”for a title. b. D That 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. . RAdditional Orders Requested ask the court to make the following additional orders (specifiz): D Check here iftlzere is n0! enough spacefor your answer. Put your complete answer on (he attached sheet 0f paper orform MC-025 and nrire ”Attachment 16-Addili0nal Orders Requested,’'for a title.* "‘-/\‘ " \Aah. .4-‘"o.) ” In- ‘ ® Number of pages attached to this form, if any: _;_ Date: SelhRepmsented- . d ’ SeIf-RepmsenteL___ Lawyer 's name (Ifany) Lawyer ’s signature V I declare under penalty of perjury under the laws of the State of California that the information above and on all attachments is true and orrect. Date: GulwwmVeka’zmhoz Type or print your name ’Sign your name gmgucm WQU‘UL This is not a Court Order. mmm‘m 12°” Request for Civil Harassment Restraining Orders CH-1oo. Page 6 ore (113' 3rm (Civil Harassment Prevention) 1O 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 ZICH009833 CASE NAME: 3‘ 64v}: Zflgg elabficWA‘se #:as ame as ame CH-1 00, Item 7a(3) - DESCRIBE HARASSMENT: a) How do you know the person you want to restrain? b) Are you living with the person? D YES fl/NO c) Has the person U physically abuse youéphysically or verbally threatened you and/or grassed you many times? 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WMgufl hog )qwaen becew W$ 0mm m mm MbmszWMVC dchhve mum Wued owe Home Come \nonwa agam 5% WM 000m mom 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 216H00983 CASE NAME: and CASE #z Last Name Last Name e) Were any guns or other weapons used or threatened to be used during any abuse in the past three months? YES D NO If "YES". describe: mmuA 0m 968 ¥D\\nvf\ m )(wcnmgx am; QM ”Pdw {ropmW f) Were there any injuries during abuse In the past three months? EYESm0 If “YES”. describe: g) Did the police come to any of these recent events? ms D NO h) Did they give you an Emergency Protective Order for abuse in the past three months? El YES 9N6 If “YES". please attach a copy. i) ls the person you want to restrain in jail right now for violence against you? E1 YESm If "YES". where: j) Has the person you want restrained ever been in jail for violence against you or your children? UYESm lf“YES".when: Describe what the person did to you or your children that caused them to go to jail: CH-100, Item 73(3) - DESCRIBE HARASSMENT Page_ 1O 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 ‘ ‘ 210H00983Velmggfim 9101mm“ CASE NAME: CASE #z Last Name Last Name k) Do you have a criminal protective order (restraining order from criminal court)? D YES (B(O If “YES", please attach a copy. I) Describe the worst abuse and when it happened: fl’TfiE’most recent abuse i_s the worst abuse OR Worst abuse was (approximareaane) | l 131 LI andthe person I want a restraining order against (describe wnanneyau :oyou): :5 fl: fleasma W Wynn) 'hjyk ‘I (\mx/W Wm] Wm :r W: m3 H932 orM QLVLOL \mKJr w, (“j Mu J LpLWAfi +b3 \K I Mow? 449p? mgss Junta 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-100, Item 73(3) -- DESCRIBE HARASSMENT Page
