*****THIS FORM IS NOT A PROTECTIVE ORDER APPLICATION OR A PROTECTIVE ORDER*****

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1 SHAREN WILSON CRIMINAL DISTRICT ATTORNEY OF TARRANT COUNTY, TEXAS PROTECTIVE ORDERS Family Law Center Phone Number East Weatherford Street # 3040 Fax Number Fort Worth, Texas WHAT IS A PROTECTIVE ORDER? A final protective order is a civil court order issued by a District Court to prevent continuing acts of family violence, dating violence, stalking or sexual assault against the victim and the victim s household members. It is not the same as a restraining order. Violation of a protective order may result in criminal prosecution, and includes the potential for jail/prison time and/or fine for the offender. A protective order may order the abuser to: stay a specified distance, such as 200 yards or more, away from the addresses listed in the order, generally your home, school and work addresses; not commit or threaten to commit violence against you or members of your family; not communicate with you in a threatening or harassing manner - directly or through someone else; not communicate with you at all, except through attorneys and court-appointed persons; not follow you (for Stalking Protective Orders only); not possess any weapons unless that person is a peace officer; not remove or harm your pets or companion animals; and not remove children from your care. The Criminal District Attorney s Office does not issue protective orders. Only a judge can grant a protective order. After one or multiple court hearings, if the judge grants the protective order, your local police or sheriff s department will be sent a copy of the order. If the person complained against commits any of the prohibited acts listed in the Protective Order, criminal charges can be filed by law enforcement if there is sufficient proof of a violation. Page 1 of 13

2 2. THE PROTECTIVE ORDER PROCESS How do I get started? Complete this questionnaire. USE BLACK INK ONLY If you print this form and fill it out by hand, do not use other ink colors, including blue. Do not use pencil. WRITE LEGIBLY - Printing or typing is preferred. Return the completed questionnaire to this office: By By fax: By mail***: Tarrant County Criminal District Attorney Protective Orders Family Law Center 200 East Weatherford Street, Suite 3040 Fort Worth, Texas ***This usually requires at least two stamps. In person: Between the hours of 7:45 a.m. to 5:00 p.m., Monday through Friday, at the Tarrant County Criminal District Attorney Protective Order office. If you have any questions, you may call this office at between the hours of 7:45 a.m. and 5:30 p.m., Monday through Friday. You ve completed and submitted the questionnaire. What s next? Typically, within 2-3 business days after your questionnaire is received, you will receive a call from a Protective Order support staff person to obtain any missing or incomplete information. After that, an Assistant Criminal District Attorney will call you to discuss your questionnaire and determine if the Criminal District Attorney s Office may file an Application for a Protective Order for you. You may contact this office to check on the status of your questionnaire at any time. If we are unable to assist you, we will provide you with referrals as may be appropriate. You must attend at least one in-person appointment at our offices. Generally, a court date will be set for within 14 days of your in-person appointment. If your case is accepted, an Assistant Criminal District Attorney will obtain an affidavit from you detailing relevant facts of the case, file the protective order lawsuit and represent you in court. Depending on the circumstances, a final protective order may take 4 weeks or more to obtain. Our staff and attorneys will work to accommodate your schedule as much as Page 2 of 13

3 possible. However, there are certain aspects of the court process that we do not control. Court appearances are always during the week, Monday through Thursday. You must be present for court at 8:00 a.m. on your designated court day. 3. WILL I GET A PROTECTIVE ORDER? Based on the information you provide to us, we will assess your request and determine whether the necessary relationship requirements are met, and whether the bad acts you describe meet the code requirements to support filing a Protective Order Application on your behalf. If your primary issue is divorce, child custody, visitation, child support or a property dispute, this office will not file an Application for a Protective Order. You may consult a private attorney for advice on those issues. If you would like the Protective Order to review the facts of your situation to determine whether we may assist you, please complete and submit this questionnaire. It is the policy of the Criminal District Attorney that all services and activities of the office are accessible to all qualified persons without regard to disability. If you have a disability that will require an accommodation, please notify us. If you are hearing impaired, blind or visually-impaired, you may call Relay Texas at 711 from any phone or visit Page 3 of 13

4 Today s date: SECTION I: NAMES OF PARTIES Your name: ( ) First Middle Last Other last names used Full name of the person you want a protective order against (List only one person): ( ) First Middle Last Other last names used What is your current relationship to this person? (Check ONLY one.) Married - living together Married - not living together Divorced Living together - not married Used to live together - never married Related by marriage Biological parents of the same child - never married Dating or used to date Other - please specify: Related by blood please specify: SECTION II: YOUR PERSONAL INFORMATION Your race or ethnicity: White African American Asian American Pacific Islander Hispanic Native American Other - specify: Sex: Male Female Date of Birth: Age: Place of Birth: *If you are female, are you pregnant? Maybe/don t know *If you are female, has this person ever abused you while you were pregnant? Do you have any handicaps or disabilities? If yes, what is your handicap or disability? Visual impairment Hearing impairment Mobility or functional impairment Emotional or mental disorders Cardiac and circulatory diseases Respiratory diseases Other physical handicap or disabling condition - please specify: Have you ever been arrested, convicted, put on probation, or given a ticket for an act you committed against ANY PERSON? If yes, please briefly explain, include dates: Has anyone ever applied for or gotten a protective order against you? If yes, please explain: How did you find out about this office? Law enforcement agency - please specify: Judge or justice of the peace Mental health services Hospital/Doctor/Nurse/Medical Professional Social service agency - please specify: Page 4 of 13

5 Other - please specify: Where do you live today? SECTION III: YOUR HOUSEHOLD INFORMATION Street Address Apartment # City State Zip Code When you call 911 from this address, which police department responds? **Does the abuser know where you live today? Yes No Names and contact information for any other ADULTS currently living in your household. Please explain your relationship with these adults: What is YOUR mailing address? (if different from above): Street Address Apartment # City State Zip Code Home Phone # Cell Phone # address: Does our office have permission to leave messages at the above phone numbers? **This office will not leave messages at any number provided if you are still living with your abuser. You will need to contact our office to find out the status of your questionnaire. If you have any minor children, please provide the following information: Child s Name Age Date of Birth Sex Live with you M F M F M F M F M F M F M F Page 5 of 13

6 If you have minor children NOT living with you, briefly explain why: Do any of your children have any handicaps or disabilities? If yes, please indicate type of handicap or disability after that child s name in the space above. Is the abuser the parent of any of these children? If yes, which children? Are there any court orders [temporary or final] that include any of your children? If known, what court issued the order? Cause# Has the abuser ever harmed any of your children? If yes, complete the following: Date(s) of abuse: Name of child/children: Briefly describe the incident(s): Has Texas Department of Family and Protective Services (TDFPS formerly CPS) ever been notified?** If yes, provide the following information: Date City/State Name of case worker Phone # and extension Have the police ever been notified of child abuse? If yes, provide the following information: Date City/State Name of Officer/Detective Phone # Case # Have criminal charges ever been filed against this person for child abuse? If yes, please list the date, county, and case # (if known): **This office may make a report to TDFPS if we believe a child has been harmed and no report has been filed. Page 6 of 13

7 SECTION IV: YOUR EMPLOYMENT/SCHOOL AND OTHER CONTACT INFORMATION Are you currently employed? If yes, what is your current job? If you are currently employed, please list: Employer Phone # Street Address City State Zip Code List the days and hours that you work: When you call 911 from this address, which police department responds?: Does the abuser know where you work? Are you currently attending school? If you are currently attending school, please list: School Phone # Street Address City State Zip Code List the days and hours that you attend class: When you call 911 from this address, which police department responds?: Does the abuser know where you attend school? Friend or Relative (not living with you) who will always be able to locate you: Name: Relationship: Address: Street Address Apartment # City State Zip Code Home Phone Cell Phone Work Phone In the event we cannot find you, may we call the above named person(s)? Does this office have permission to leave a message with the above named person(s)? Page 7 of 13

8 SECTION V: INFORMATION ABOUT THE ALLEGED ABUSER Name: ( ) First Middle Last Maiden, if applicable What other names does this person use? Sex: Male Female Age: Date of birth: Social Security No.: Place of birth: Driver s License No. and State: Home address: Street Address Apartment # City State Zip Code Home Phone No. Cell Phone No. When is the best time to find this person at home? Is he/she currently employed? If yes, please complete the following: Occupation: Employer Work Phone No. Street Address City Zip Code Days and hours at work: Is there any other address where this person can be found? If yes, please complete the following: Person who lives at address: Phone #: Street Address Apartment # City Texas Zip Code Physical Description: Height: Weight: Race/ethnicity: Complexion: Hair color: Eye color: Glasses? Contacts? Color of contacts? Facial hair? Page 8 of 13

9 Tattoos? If any, describe: Scars? If any, describe: Body piercing? If any, describe: Other identifying characteristics: What kind of vehicle does this person drive? Year: Make: Model: Color: License plate no.: Does he/she have any weapons? If yes, please list: Is this person currently on parole or probation? If yes, provide the following information: Parole/Probation Officer s Name: Phone # Reason this person is currently on parole or probation: SECTION VI: RELATIONSHIP INFORMATION When did you meet this person? When did you start dating this person? When did you stop dating this person? Did you ever live with this person? If yes, when did you start living together? Were you ever married to this person? If yes, where and when were you married? Are you currently living with this person? When did you stop living together? While you were living together, did you ever separate from this person? If yes, how many times? For how long? Have either one of you filed for a divorce from each other? If yes, when? What county and state? If you are DIVORCED from this person: When was your divorce final? What county and state? Have you ever been granted a protective order against this person before? If yes, when and where (county and state)? Do you currently have an emergency protective order? If yes, through which police department? Page 9 of 13

10 Has this person ever applied for or gotten a protective order against you? If yes, please explain: Have you ever hit, slapped, pushed, bitten, kicked, spit at, or otherwise physically hurt, threatened, or used a weapon against this person? If yes, please explain: Have you ever received any kind of health care because of abuse in this relationship? If yes, please briefly specify reason and dates. Emergency room Hospitalization Counseling or psychotherapy Doctor s care Dental care SECTION VII: DETAILS ABOUT DOMESTIC VIOLENCE/SEXUAL ASSAULT/STALKING The information provided will help us make a determination whether our office can assist you. Please use the space provided to list three (3) recent incidents where the abuser has physically harmed you, threatened physical harm, or has caused bodily injury, assault or sexual assault. If the abuser has been harassing or stalking you, list incidents of that behavior or the incidents that have placed you in fear of IMMINENT physical harm, bodily injury, assault or sexual assault. If you need additional space to answer any question in this section, please attach separate sheets of paper. Date of the MOST RECENT incident: Briefly describe what happened: Were weapons or objects used on you? If yes, what kind? Were you injured? Page 10 of 13

11 If yes, describe your injuries: Are there photos of your injuries? Any witnesses? If yes, please provide names and contact information: Were the police called? If yes, which police department responded? What did the police do? Report number Date of INCIDENT #2: Briefly describe what happened: Were weapons or objects used on you? If yes, what kind? Were you injured? If yes, describe your injuries: Page 11 of 13

12 Are there photos of your injuries? Any witnesses? If yes, please provide names and contact information: Were the police called? If yes, which police department responded? What did the police do? Report number Date of INCIDENT #3: Briefly describe happened: Were weapons or objects used on you? If yes, what kind? Were you injured? If yes, describe your injuries: Are there photos of your injuries? Any witnesses? If yes, please provide names and contact information: Were the police called? If yes, which police department responded? What did the police do? Page 12 of 13

13 Report number I have read and understand the following: The information that is provided in this questionnaire is for the use of the Tarrant County Criminal District Attorney s Office only and will be kept confidential unless we are required by law to release or report any information. This office receives federal grant funds, so it is necessary to request some statistical information from you. This information is used only to prepare reports to show compliance with federal nondiscrimination requirements. This information has no bearing on whether or not you qualify for services through this office. A protective order is not a criminal charge. Criminal acts must be reported to a law enforcement agency in order to be prosecuted. If you have suffered personal injury as a result of a criminal act, you may qualify for crime victims compensation benefits. To be eligible for consideration, you must report the crime to law enforcement within a reasonable period of time, but not so late as to interfere with or hamper the investigation and prosecution of the crime. For more information you may contact the victim assistance liaison at the appropriate law enforcement agency. I,, affirm that the incidents and the information contained herein are true and correct to the best of my knowledge. Signature Date Page 13 of 13

*****THIS FORM IS NOT A PROTECTIVE ORDER APPLICATION OR A PROTECTIVE ORDER*****

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