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DV..100
0Na~e

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Request for Domestic Violence.Res.t~~ining Or.d~r,

,;Clerk stamps date here

when farm is filed.

You must also complete Form CLE.TS:..,OO 1~Confidential CLETS Information and give it to the clerk when you file this Request. ,Of person asking for protection:
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tll Suu~,dor

Court

_M~,a_.n_o_.F_H_Je_'m_·_an_:·~_.'.~_~z_L~" . __ __

Age: _4_'7

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JUL 0, 3 ZOll

Your lawyer in this case (if you have one): Name: State Bar No.: ............................_
Firm Name!
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tnformation. If you do not have a lawyer and l1'a.nt to keep your home address private, ,give a different mailing' address instead. You do not have to' give your telephone, fax, or e-mail.) ~" Address: ,ADD'.RE.S:S CONFJ,OIENTIAL
City:

Address (If you have a lawyer for this case, give your lawyer 's

Fm in coun name and street address;
,Superior Court of Califo-rni'a, County of

tOS· ANGELES 90.0 'Third Stre et 'S'an Fernando, CA 9'1:340

Telephone: E-MaU, Address:
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'NORT,H VAL,LE'y State: __ Zip: .___ .. .""""" ....._ __ Fax: _ _,.".,.,~.....:......... ....._ _ ..,......,.,~~""""__ Clerk fill-s in case number when-form -~ -..

'V Nam,e of person yo,u want. protection f'rom:
M:,aribel De La Torre Description of person you 'want: protection from;
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,Case Number: ,

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is' filed.,

Sex: 0 M' IXI F Height: .......!t............ ,5 ,.._6_'· __ Race: Hispanio Address (ifknown): ---- CIty: San fernando
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Weight; 150 I~s"

Hair Color; ~rown ._. Eye Colon Bro'wn Age: 4'1 Date of Birth:
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,0 Do y,ou want an order to p-rotect 'famUy or household
If yes, lis t them:
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State: --_ ............_........._ CA

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members?

lXi' Yes, 0 No

Nathan Hernandez

Full ll.:fY!!X
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M
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,Sex
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,Age 11

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_ Check here if you need more space. Attach a sheet of paper andwrite ~'fDV.,;100~ Protected People" for a title,

IZl 'Yes D No 8'on DYes 0 No DYe,s D No ............................
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Lives with xou,?

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Relati~nshi.gto y'Ou_

What is your relationship to the person In®? (Check all that apply): aj~ 'We~nowmaITiedorre~s~ed~m~ticpa~Ns. '·~lf-~~-':'-'u-d~~-n~o~th-C'~-~-e-:o-n-~-~-~ .• '~-:e-re-.-ro-.~-~N-.~-:n~~I-~l-~-~~ b. 0 We ,used to be married or registered domestic partners. the court may not be able to consider your o. D We. live together, request. Read DV~500-JNFO for help. d~~D~eused~live~~her~ ~~~~.. ~~~~~~~~~~~~ e.. 0 W'e are related by blood, marriage, or adopti-on (specify relationship): ........... ___........... ~~~~ ,................... """""" ___~ ....... _ f~ 00 We are dating or 'used to date, or we are or used to be engaged to be, married, g. D W'e are the parents- together of a child or children under 18:
Date of Birth: ----...,.........,_,.,..".. Date of Birth: Child's Name: Date of Birth:' ~~;'1'you.. needmore space..A ttacna siheet oj paper an. wri h \,,t".... d write' t~D-V.·'l·O·O·'C·h·ld rrd 18"/< a DCh tee.khnere if .. "Dv-I .nuaren Under l jor title. h. 0 We have signed a Voluntary Declaration of Paternity for our child o.r children. (Attach a copy if you have one).
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Child's Name: Child's Name:

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This is not a 'Court Order ..
JudkJa1 Co~ncff, d ca~romia,\IWW.courtS.OO.gO-lI l
Revised J,artuary 1, 2012! MMdat'Ory Form Family' COQ9, § 6200 et seq.

Reques·t for Domestic Violence R,estraining Order
{Domestic Vi'ol'enc,e Prevention)
DASH San Fernando

DV-100, lPag;e 1 Q.f 5
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Case Number:

a" Have you or any other person named in item ® been involved in another court cag·ewith. the person In @? ~ No 0 yes If yes, check each kind of case and indicate where and when each was filed: Kin:d,ofCase County or Tribe Where F,iled Year Filed Case Number af]~nown)

Other Court Cases

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. ",__,__ .... D Check here if you need more space; Attach a sheet of paper and write "D V J.OO Other Court Cases nfor a title. ~ b, Are there any domestic violence restraining/protective orders now (criminal, juvenile, family)? ~ No 0 Yes lfyes attach a C:OPY if you have one.
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o Domestic Violence o Criminal o Juvenile, Dependency, Guardianship o Child Support .0' Parentage, Paternity o Other (specify} ,~. __ . ..

o Divorce, Nullity, o Civil Harassment

Legal Separation

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Check the orders you want.
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Perscnal C,onduct ,Ord'ers I ask the court to order the person in ® not to do the following things 0 me or anyone ..sted in ®: i B.. 00 Harass, attack, strike, threaten, assault (se,xu.ally or otherwise), hit, follow, stalk, molest, destroy personal
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property, disturb the peace, keep under surveillance, or block movements bt IXl Contact, either directly or indirectly, in any way, including but not limited to, by telephone, 111mlor e-mail or other electronic means The person in wtll be ordered not to take any action to ge,t the addresses or locations 0/ any protected person unless the' courtfinds good cause not to make the order.

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Stay~Away O,rder

a" I ask the court to order the person in to stay at least .. .0~ 1 .yards away from (check all that apply): ~ Me [0] My vehicle [X] My h0111e lCJ The children's school 01' child 'care lXf My job or workplace IX] Each person. listed in@ ~sc~ol D O·br,~oc~:_._.~~~.~~~~~~~~~~~~ 'bt If'the person listed. in @ is. ordered to stay away from all, the places listed above, will he or she still be able to get to his or her horne, school, Job, workplace, school, or vehicle? e9 'Yes 0 No (if no, explain):

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Move-Out O'rder (If the person in ® lives wlth you and you want that person. to stay awayfrom your home; you must ask/or
this move-out order) , I ask the court to order the person ill @ to move out from and not

return to (address):

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This is not a Court Order.
Revised .January

t 2'012

Request for Domeetlc Vio.fenc,e Restraining order
(Domestic Vlolencs P'rev'ention)
DASH San Fernando
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Guns or Other Firearms and Ammunition
I believe the person in

® owns or possesses

guns, firearms, or ammunition.

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Yes ~ No

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I don't know

If the judge- approves the order, the person in (~) will be ordered not to awn~.possess, purchase or receive a firearm or ammunition. The .person will be ordered to sell to a .gun dealer or turn in (0 law enforcement any

guns or firearms that he or she owns or possesses.

IZI Record Unlawful Communications

I ask for the right to record communications made to me by the person in ® that violate the judge's orders ~

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Animals: Poseeeslon and StaYRAway Order .I ask for the sole possession" care, and control of the animals listed below. I ask th.e court to order the person in ® to stay at least , ,'yards away' from and not take, sell, transfer, encumber, conceal, molest, attack, ~~e,ilire~n,~,mo~~edi~oseofiliefullow~g~im~s:~~~~~~~,~,_~ __~~~~~_ ,
I ask for the animals to be with m'e because: --_ ............ ....-

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,C'hUd C'ustody' and' Vi,sita,tlon
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"~ i ;t.iI"II' d d, I at O .'0d no t_. :ave a Child• cus t 0 d,y or VlS1w t'on oruer anc I want one. -'-I h b~:-, I'1.nave 8. C_urc custody or vtsitation ore er an,. I want It changed ' .. 0 - h' lid'" d ~ d d _',
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lfyou askfor orders, you must/ill out and' attach Form .DV-105, Request for Child Custody and Visitation

You and the other parent mqy tell the court that you w,ant to be legal parents of the children (use Form DV~180t Agreement and Judgment of Parentage) ,
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Orders.

Child ·Suppo'rt (Check all that apply):
at,

a child support order and [want one. bIOI have a child support order and I want it changed, c.. 0 I now receive or have applied for TANF, Welfare, 'CaIWORKS, or Medi-Cal, If you askfor child support orders, you must jill out and attach Form FL-150" Income and Bxpense Declaration or Form FL-15S~, Financial Statement (Slmpllfled),
COU11. to

0 I do not have

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0 Property Control
I ask the

give oilly me temporary use, possession, and control of the property 1isted here:

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Debt Paym.ent I ask the court to order the person in @ to Ill-aleethese payments while the order is in effect: Check here (you need' more space. Attach a sheet a/paper and write I(DV;"10o., Debt Payment" for a tute: Pay to: , "_ , ' For: Amount: $ Due date: ............

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Property Restralnt
I am married to or have a regtstered domestic partnership with the person in @. I ask the judge to- order that the person in®not borrow against, sell, hide, or get rid of or destroy any possessio-ns or property, except in the usual co-urse of business or for necessities of life. I also ask the judge to order the person in to notify me of any new or blg expenses and to explain the.m to the court"

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This is not a Court Order,
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Requ·est for Domestic Vi·olence Restraining Ord'er
(Domestic Viole·nc·e Prevention) DASH San Fernando

DV·100, Pag's 3 of 5
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"Case Number:

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Spousal Su'pport I am married to or have a registered domestic partnership with the person. in. @ and no spousal support order exists, I ask the cou,rt to order the person in @to pay spousal support (You must fill out.file, and serve Form FL-150 Income and Expense Declaration, before your hearing) ..
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0 Lawyer's Fees and Costs
I ask that the person in

fees and COSts1' You must complete, file andserve Form ,FL~I 50 Income and Expense Declaration before your hearing.
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® pay' some or all ofmy lawyer's

Payments for C,osts and Serv'ices, I ask the court to order the person in @to pay 'the following: You can ask for lost earnings or your costs for services caused dtrectly by the person in ® (damaged property, medical care, counseling, temporary housing, etc.). You must bring proofof these expenses to your hearing. Pay' to: _My.se,f ...~._~_ For; Lap:~p~£o~,p~~er Amount: $.$~~O~OO
Payro:~. ~~~~~ ~ _ For: ....................... _ __......,., ............. _~._~ _....... ~........ . ~._

Amount;

$~~_

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IKl BaUerer Intervention Program I ask the court to order the person listed in ® to go tc a 52... week barterer intervention program and show proof of completion to the court.

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0 Other Orders

~h~ot~rordern,areyou~~,ngfur?_.-~~~~~~~~~~~~~~~~~~~~~~~~

o Cheat: here ifyou
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need more space. Auach. a sheet of paper and write "D V~I 00; Other Orders "for a title.

0 Time for Service (Notice)

The papers must be personally served on the person in @ at least jive days before the hearing, unless. the court orders a shorter timefor service. If you want there to be fewer than five days between service and the hearing, explain why below .. For help. read FOrm D V-200'~lNFOr "What Is Proof of Personal Service?"

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No Fee to Serve (Notify) Restrained Person If you want the sheriff or marshal to serve (notify) the restrained person about the orders for free, ask the court
clerk what you need to do.

Court Hearing The court will schedule a hearing on your request, If the judge does not make the orders effective right away ("telnporary' restraining orders"), thejudge may still make the orders after the bearing ..Ifthe Judge does not make the orders effective right away, you can ask the court to cancel the hearing ..Read Form DV-112, Waiver of Hearing on Denied Request for Temporary Restraining Order for more information.

This is not a Court Order. :
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Request for DO'm,esfic Violence R·estrai:ning Order
('D'omestic Violence Prevent.ion)
DASH San Fernando,

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Case Number:

D,escrib,e, Abuse
Describe how the person in® abused you. Abuse means to intentionally or recklessly cause or attempt to cause bodily injury to you; or to place you or another person in reasonable fear of imminent serious bodily injury; or to molest, attack, hit; stalk, threaten, batter, harass, telephone, or contact you; or to disturb your peace; or to destroy your personal property, Abuse can. be spoken, written, or physical. (For a complete definition, see Family Code §,§' 6203 6320) a. Date of most recent abuse! J'une-28 ... 201_2 b. Who was there? ~ __.._ __. _
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c, Describe how the person in

® abused you 'or your children:

See Att.a'ched De~larati?'~,~,(~V~1'OO,_[te~ ~~~nt Abuse) ~.:

"D v:. 100, Recent Abuse "for a title. d. Did. the person in ® use or threaten to use a gun or any other weapon? lIZ] No, '0 Yes (If yes, describe)
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o Check: here if you need more space. Attach a sheet of paper and write
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e. Describe any injuries: .~,e,~Attache d DecraraU,t?n ([)_y-1~Q_O,Item 2 5 ~ Recent Abu ~~)
£ Did the police come? 0 No 1[1 Yes If yes; did they give you or the person in

Attach Q' copy if you have 'one. T'h,eorder protects ,0 you or

® an Emergency
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Protective Order?

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Yes

IENo 0

I: don't know'

gMi Has fhe person in
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you (or your children) other times? /fyes 0: check here and use Form ,DV-J Ol, Description of Abuse or a sheet of'paper to describe any previous. abuse.

® abused

0 the person in ®

Other Persons to Be Protecte·d The persons listed In ite,m@ need 811 order for protection because (describe): Because I am afr.aid of Rp1s, violent
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behavior,

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Number of pages attached to this form, if any:

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I declare under penalty of'perjury under the laws of the State of California that the Information above is true and correct. Date: Jurv 3,. 201.2 Type or print your name Date:
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M.ario F Hernandez

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L.awyer 's name, if you have' one
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This is not a Court Order, Request for Domestic Vlolenee Restrain'ing Order
(D'o·mestic Vi'olence Prevention)
DASH S,an Fernando

DV..1 ~O, Page 5 of 5

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Hernandez vs, De La Torre F orin D'V ... 00.; Item :25 1

Case No.:

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f am the Petitioner in this case. Maribel 'De La,Torre is, the Respondent
("RP"). RP and I are dating (or used to date). I am father of a son, Nathan

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,4 - Hernandez, who is a rnlnor (1'1 years old). RP and I do not have any children
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together.
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On June-,.28 ..2,012, RP abused m·e physically, threatened to k,ill me, and
destroyed my personal belonging. RP was upset with rre because she felt that I dld

8 9. not tell her about a trip a head of time and she did not want me to go on this trip,

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which I planned for the weekend, During a phone conversationrRP
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told me that she

was coming over. to retrieve her [P,ad~I reminded her that the iPad was a gift from.

12' her to me on my last birthday. RP wanted the iPad back so she was on her way to

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t. ,"' . ". . ",.... _ _" ~'.' ...:." ,"_ my house to pick it up I knew that she was up'set' - 8-0' ld eclded to come. ," outslde'. ..' the.
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door and prepared to step outside. At this time .RP arrived and pushed me back

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throughout the room. RP then grabbed' a glass frame dra,wi'ng and smashed it on the floor, ~ ,causing" the g'lass and the frame to shatter on the, bedroom floor, I asked her to

2,4: calm down and leave, but she refused. ,S·he, said "you are not fucken '901n'9 25' 26,

anywhere,"

RP then grab'bed the laptop, computer and told me

that she was not

" going to give it back to me until she got the iPad. 1told her that I dld not have the 271 iP.ad~ ,RP then slammed my laptop Q,nthe bedroom floor causlnq it to break, .2·8 D'ASH S·an Fern,a:n,do Page 10,f2
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Hernandez
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De La Torre
Form DV-IOO, Item 25

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fucken hate you. I hate you for what have done to me." RP claimed that I was not
truthful with her about the trip and that I played' emotlonal games with her, I told RP

,5, that there ls no reason for her to get: upsetabout the trip because it was a last
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minute decision that made. but she stlll was 've,ry upset, R,P then grabbed me by my
neck and with both of her hands and beqan to squeeze my throat and said "now I

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oi,ng.'·to fuck:en kin you f was able to break free 'from her, RP then followed' me

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around the bedroom and continued to throw' punches on my arms and my other
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11 ~ body parts as I was, tryin'Q to protect myself. RP then for the second time strangled

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me and I struggled to break free from him. Finally RP left my home. I then called the

Iii ' -,", " po Ice and pollee came and wrote, a report.
I ask the Court to order RP to pay the amount of $40,0,00 for my laptop

151 16

destroyed by her during the incident of abuse.

I res"pectfuUy ask the Judge to grant me this restraining order protecting me
18' and my son because I am afraid ot RP's 'violent behavior and I do not know what 19 type of brutal behavior RP would be capable of in future if she is allowed to get near . ', 20 me
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DA:SH Sa:n Fernando

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