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aH4.q)- DaR :\IAR\"L: 'D fOR MontgomeI)'County


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8552 SECOND AVENUE . r-..J_/\ 2-5P 18'-l '2 -
LocaL..a at
SlLVER
SPRINct Ml)iUDftDi Case o. Vl-V<..I 0 '7
. 'OTE. Fill in the DlIOl,ing. checking 1/-.e approprime boxes. p" iii neTS neednot gh'e an address ifdomg 50 ri51u WI -
further abuse or ro?\."ea s confidential ddress ofa sheller. If.his Iri! c. c, cr.zck here Ifyau d add:tional
_cI<!lr" )
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) hiuing .. ilb objecl 0 stabbing
etainin!!: a!!:2.ins will -in!!. 0 biting
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PETITION FOR PROTECTION FROM
DOMESTIC VIOLENCE CHILD ABUSE VULNERABLE ADULT ABUSE
I. I '3:1 heffu m .. I y
e Respon 'mt mmirted me followi g acts ofab:I5e ag'il:> her" V1.
on or a :J- -3-/3 ( hee' a.! mat a;Jply.) hoki g.suangling
oar;
o sla pi g shooting rape or ether _exual offense (or 2rre
o shoving th eats of violen e i ; oi a hil
G.tO ,er abUSe...
Respoc. e
.-\ his "-ime the v: 'm can be found at _
I am State's A omey DSS 0 a rela 've an a I In,;n=: i me me.
1. e er3 0(5) I ant pro ec ed are (include }ollrsdfifYau are ,,'c im):
I
-'ames(s) J ' B' " ::
J 'JI.,Wthev/lvt I-/-J-04
J l[-.t4 -qq
If - /6 - 80
CC-D VI (Re 10 _0] I)
fi r he fnllowing period ohime during 4, the pe n()1 \ 'ant, rOlec ell n w li....es. or has Ii e ,'ith he R15 .1e
the past _
There Dare 0 are not additional persons living in the home,
5. I k fme Col 0\ 'jng court cases in -01 ing me, or the P r!On I \":t, t 3; the Res nden (Exan:ples
in;:1 c it support, divor e, 00
0
', d.., .eslie ,-i Ie ceo ' ,min'll ases)
Coun 'ind of Case .ear F:led Result or S il,US (if O!J kno \)
6, I ave recei oed a mal protectj 'e 0 er ag-" ..s: s::u::e
abuse allege in is petition. and which" 'as 'ssued fi a ])ericd
Ore l5med _ -e e. ueil _
3
l . n where issue
r has access to e
ahuse.}
Ell/off
10 go to The residencers)

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PETITIO FOR PROTECTIONiPEACE ORDER
CONTINUATJO SHEET
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