Case Document Entered on FLSD Docket Page of Case Document Entered on FLSD Docket Page of IN THE CIRCUIT COURT OF THE FIFTEENTH JUDICIAL CIRCUIT IN AND FOR PALM BEACH COUNTY FLORIDA Case No DA Dfl jc S"".X.kx:Jctn8 ion Petitioner Ji VI I full legal name following statements are true being sworn certify that the SECTION Case Document Entered on FLSD Docket Page of Case Document Entered on FLSD Docket Page of SECTION II RESPONDENT This section is about the person you want to be protected from It must be completed Petitioner has known Respondent since date Ton 1.av A I I Respondents last known place of employment _u c.r Employment address Working hours N4.lf Physical description of Respondent Race __ Sex Female_ DateofBirth I ICf Height Weight Eye Color Hair Color I ond Distinguishing marks and/or scars YO o.v IO CF PC cu-id c.v Vehicle make/model A Color:N A Tag Number:_ __ Other names Respondent goes by aliases or nicknames Respondents attorneys name address and telephone number If you do not know whether Respondent has an attorney write unknown If Respondent does not have an attorney write none If Respondent is a minor the address of Respondents parent or legal guardian is tJ OY SECTION I CASE HISTORY AND REASON FOR SEEKING Case Document Entered on FLSD Docket Page of Case Document Entered on FLSD Docket Page of Has Petitioner ever received or tried to get an injunction for protection against domestic violence dating yiolence or repeat violence against Respondent in this or any other court Yes V,-No If yes what happened in that case include case number if known Ji Has Respondent ever received or tried to get an iajunction for protection against domestic violence dating violence or repeat violence against Petitioner in this or any other court Yes 0No Ifyes,whathappenedinthatcase includecasenumber.ifknown Describe any other court case that is either going on now or that happened in the past between Petitioner and Respondent include case number if known None Respondent has directed an incident of violence meaning assault aggravated assault battery aggravated battery sexual assault sexual battery stalking aggravated stalking kidnaping or false imprisonment or any criminal offense resulting in physical injury or death against Petitioner or a member of Petitioners immediate family The incident including date and location is described below On date I z.o I au at location c2tIT i-ic ic1 gg c:tt Gyc ll wnr tnu I ocrs cnec,1.1 i on hhYJ Pre:ot on cwted Chet inq tn:c rna!v rnco 1nc0 i rkrxrte4f rc lt Zl 2s i iill cfv ne a JJUlLI L.1.JJO.U:.:JQ.O c..CJJLC Lru:.d 243illi.m QL_m-c heck here if you are attaching additional pages to continue these facts Other prior incidents including dates and location On date if 2.Qbbl at location Respondent LC vveve qrQ A,i OC PYC llif aE f2fE_ 1iti Florida Supreme Cour1 Approved Family Law Form Petitt on for Jn,iuncticm for Protection Agahlst Dating Viotenee Pap3ofS Case Document Entered on FLSD Docket Page of Case Document Entered on FLSD Docket Page of DATE I DA Case Document Entered on FLSD Docket Page of Case Document Entered on FLSD Docket Page of Check here if you are attaching additional pages to continue these facts Petitioner genuinely fears dating violence by Respondent Explain Am fectV or:c A-i be ou I I Additional Information all that apply a Respondent owns has and/or is known to have guns or other weapons Describeweapon This or prior acts of dating violence have been previously reported to person or agency KO-..IC po 1m B:CCl c:l Cll Cl fqJV o:ac.A OGl SECTION IV INJUNCTION This section must be completed I Petitioner asks the Court to enter an injunction prohibiting Respondent from committing any acts of violence against Petitioner and a prohibiting Respondent from going to or within feet of any place Petitioner lives prohibiting Respondent from going to or within feet of Petitioners place of employment or the school that Petition ress etitio of employment and/or school is pro ting Respondent contacting Petitioner by telephone mail by e-mail in writing through another person or in any other manner ordering Respondent not to use or possess any guns or firearms that apply L_ prohibiting Respondent from going to or within feet of the following place Petitioner or Petitioners i1me te fl IJi to often I Fl el I RCIV t,ul,Ql:C tl ltJ UI re Nt.U rt c.e prohibiting Respondent from knowingly and intentionally going to or within feet of Petitioners motor vehicle and any other terms the Court deems necessary for the safety of Petitioner and Petitioners immediate family I UNDERSTAND THAT BY FILINGTms Case Document Entered on FLSD Docket Page of Case Document Entered on FLSD Docket Page of I UNDERSTAND THAT I AM SWEARING OR AFFIRMING UNDER OATH TO THE TRUTHFULNESS OF THE CLAIMS MADE IN THIS Case Document Entered on FLSD Docket Page of Case Document Entered on FLSD Docket Page of AoNDENT DESCRIPTION Case Document Entered on FLSD Docket Page of Case Document Entered on FLSD Docket Page of tn6 CASB NUMBER JOl Df I B;i
