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APPLICATION AND DECLARATION FOR ORDER (Domestic Violence Prevention Act Uniform parentage Actl orcunATtoN uNDER uNtFoRM cusroDy oF MtNoRs Acr

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(TH'S

'S

NOT

AN ORDER)

Read the instructions lor Order Prohibiting Domestic Violence before completing this form,

1. This application is brought under the lcheck at least one):

a.

Domestic Violencs Prevention Act. Plaintiff and defendan I bheck at least one) i (1) are married and no dissolution, legal separation, or nullity proceeding is pending. were formerly married to each other. t2l (3) are related to each other by blood, marriagg or adoption. (4' live together.
(5t (6)

formerly liveJfeqether.
have had a 6atinglr engagement relationship. are parents together of a child and the male parent is the presumed father under Civil Code section TOOO et seq.

t7t

b'

T_l

Unilorm Parentage age Act.

Act.

The parties have a minor child in common and an action has been filed under the Uniform parent-

2.

a. The defendant's date of birth /datel- ! b. The defendant's race (specify): InA,i,z^
(Name):

L^+ .)

\r*)u_ b+

(required by Code of Civit Procedure section 55O(bD.

a. b.

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c.

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Describe e in detail the most rCbent rcbent incihents incibents of abusa abuse- State state whaffiappened, whaHannanor{ the tha dates, r{a+aa who did what to whom, and describe any -"' iniuries' Also describe any history of abuse. ll more space is needed, attach additional pages tti" ;;;;

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6\Va.{ (,V *o! has intentionally or reckle ssly bheck at least one)i caused or attempted bodily inlury to me or another. caused or attempted sexual assault on me cir another. made me or another'/".i,'" of phvsical or emotionat harm. k*rj p,1L\ WA<tLy' +-frc.l/r S " ?-1r"1

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Judici.l Council ot Catitornie
1296 [Rcv. January 1, 19911

Fo?m Adopted by Bute 1296

APPLICATION AND DECLARATTON (Domestlc Violence Prevention Uniform parentagot

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DEFENDANT lNemel;

All a,*
(THIS

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Tl

'S

NOT

AN ORDEN)
be ordered now and effectlve untll the hearlng.

cHrLD

cusroDy AND vtstrATtoN
ioint custodyl

l-l fo

I request the custody orders shown in the following columns:
List the name of the parent who should
get mle phyaical custody of th6 child be-

List th6 child's name below

ioint, write the word "joint')

low lif you want physical custody to be

g6t .016 lega! custody of rhe child below lif you want legal custody to be joint,

List th6 namo of the parent who should

write the word "joint"l

b.

[-l

visitation
Defendant should have the right to visit the children as follows:

(11

(2)

l--l n

none.

visitation with the following restrictions (specifyl:

c. lneed this custody and visitation order because of the following tac:s lspecify)l

[lf you rcquest
9.

an otder for child

n

cHtLD suppoRr l-l I am receiving public assistance. b' n Defendant should be ordered to pay support as specified, commencing on (date):

suppofi, attorney fees, ot costs, attach a completad lncome and Erpcnse Declantion tFamlly Lawl.]

a.

Child's

name

Bir.thdate

Mont[ggn1

c.
10.

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I

I request that a wage assignment be issued.

T-l

PRoPER|TY

a'

lspecify):

effective untll the hearrng. _-.^,. _! --^Lrequest that I be given the exclusive temporary use, possession, and contror of the following property we own or are buying

coNTRoL

Ero

be ordered now and

b. The order is necessary because (specify):

(Continued on reversel
1296 lFev. JEnuary

Page

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t, t99tl

(Domestic Violence Prevention

APPLICATION AND DECLARATION - Unilotm parentage)

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