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Request for Orders to

Stop Harassment'
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A1'iGBLES $UPERIOR COURT

Your address (skip this if you have a lawyer): (If you want your N(]v 2 7, ?01t
address to be private, give a mailing address instead):
52zz u] trsT JOHi\ A, OISHKE, OTERK
il **,**
3YA. GALAP6N. DHUTY
state: th z4.7353e
Your telephone number (optional):( _ )
Your Iawyer ({you have one): (Name, address, telephone
number, qnd State Bar number): Fill in coud name and stteet address
Superior Court of California, County of
SupertrCodrt H€{6 Diery
420lt4thSmeetWoer "
rson.you want protection from. I;"ap"+q$er, CA 9353d.+1fi&

Describetheperson: Sex: ffi.M nn W.igtt, Q /7fl

Heighr: .:'A, xu"., 4)1ff, Hair coior: 8l€^ fuiO
Eye Color: JJl,,r Age: Cf 2- Date of Birlh,----'-
Home Addr,e ss (if you t r"*i, 3K 333 n+l S eT ff -
ciq: ff-lhh D4/E @ stat". CA zip: ?353/
Work Address (tf you know):
City: State: Zip:
Besides you, who needs protection'? (Family or household members)
Sex Aee Lives with you? -How are thpv related to you?
7 TS 8"., DNo
n L, fly., ENo
n ZZ., fives nNo
I lto tt S tlAt-' n 2"1( q"., ! No 50
Z Check here if you need more space. Attach a sheet of paper and write "CH-100, item 3-Describe Protected
Persons" at the top of the page.
(, Why are you filing in this court? (Check all that apply);
S ff,. person in @ lives in this county.
M t *^ hurt (physically or emotionally) by rhe person in @here.
I Other kpecfy).

@ How do you know the person in@? (Describe);

Judicisl Counql of Calflffiia, ffi.coudinfo.a.gov

Revised July 1.2007, Mandalory Fm Request
' for Orders to Stop Harassment CH-100, Page r ol +
Code o{ Civil Prredure, 55 527 6 and 527.9
(Civil Harassmerit) -)
 Describe how the person in @ has harassed you
a. Date of most recent harassment: 5
b. Who was there?

c. Did the person in @ commit any acts of violence or threaten to commit any acts of violence against you?
Ey.r D No
Ifyes, describe those acts or threats:
t DJu 11

'o
F-;Eq
d. Did the person in @ engage in a course 6f conduct that harassed you and caused substantial emotional
distress? S ves fl
Ifyes, describe:

e. Did the conduct of the person in@ described above seriously alarm, annoy, or harass you? ElYes I No

J Checy here if you need more space. Attach a sheet of paper and write "CH-|00, item 6-Describe
Harossment" at the top of the page.

Check the orders you want EI

C @ Personat Conduct orders

I ask the court to order the person in @ to not do the following things to me or anyone listed in @ :
u. EhHar*s, attack, strike, threaten, assault (sexually or otherwise), hit, follow, stalk, destroy personal
proporty, keep under surveillance, or block movements'
b.€l Contact (either directly or indirectly), or telephone, or send messages or mail or e-mail'
The person in @ will also be ordered not to take any action to get the addresses or locations of any protected
persons, their family members, or their caretakers unless the court finds goo? Eauseiot to make the order'

e, @ Stay-Away Orders
I ask the court to order the person in @ to stay at least (specify) 1fl0 yards away froln 39
and the people listed in @ and the places listed below: (Check all that apply)'
a. E My home a.,EI My vehicle
U.E] Uy joU or workplace e. n Other (specrfy).
c.€. My children's school or child care
If the court orders the person in @ to stay away from all the places listed above, will that person
stillbe able to get to his or her home, school, or job? EII y"s n No
If no, explain:

Request
' for Orders to Stop Harassment
(Civil Harassment)

tr7 ff,,,
) )
 Case Number:

vL,r!- rarr,e: (eat d 5/rA,"/ rk< m

3 V others to Be Protected
Should the other people listed in @ also be covered by the orders described above?
E-Y"t f, Does not apply
If yes, explain:

(p Order About Guns or Other Firearms

I ask the court to order the person in@ to be prohibited from owning, possessing, purchasing, or receiving, or
attempting to purchase or receive firearms and to sell or turn in any guns or firearms that he or she controis.

@H Other Orders
gpecrfu); 9/fr, "1, Ffrl( l/
Iaskthecourttoorderthepersonin@to l-h
r4freftLfr LilL lloew{

@& Temporary Orders

Do you uant the court to make orders now on the matters listed in@, through @ that will last until the
nearing? Et'es I Xo
I-i les exp.atn tt hr-icu neeri these orCers right now t'/e /,
e - _t.
brtplt

Cce;i. te.e.:icu nee.i mc.e:r::e -t-!:icn a sheet of paper andwrite "CH-100, item l2-Temporary
S*ders ' et the :op ctr :ne:dge

r13 Delivery of Orders to Law Enforcement

.\,1r .asrer or I u'ill eive copics,qf te ro :he iollorving law enforcement agencies:
a \a.-ne of Agency: 4/tn ,

sr4r, Q-f zip: fz5 il

.{ddress:
Cit'-: State: _ Zip:

@il Other Court Cases

Have you ever asked any court for other restraining orCers agalnst rhe person in@l I yes ff! fo
If yes, specify the counties and case numbers if you know them

Reused July 1. 2007

Request for Orders to Stop Harassment cH-100, Page 3 :'I
(Civil Harassment) +
 Case Number:

Your name: CLfrre s//W

You must have your papers personally served on (notify) the person in @ at least 5 days before the hearing,
unless the court orders a different time for service. (Form CH-135 explains "What Is Proof of Service?" Form
CH-l 30 may be used lo show the court that the papers have been served.) Ifyour papers cannot be served at
least 5 days before the hearing and you need more time, explain why:

@4 No Fee for Filing

I ask the court to waive the filing fee because the person in@ has used or threatened to use violence against
me, has stalked me, or has acted or spoken in some other way that makes me reasonably fear violence. I am
asking for a restraining order to stop this conduct.

@ tr No Fee to Serve orders

I ask the court to order the sheriff or marshal to serve (notifo) the person in @ about the orders for free because:
u. I tUy request for orders is based on stalking; or
b. I My request for orders is based on a credible threat of violence; or
c' ! I am entitled to a fee ,*'aiver.
(If you are requesring free service of the orders based on a fee waiver, you must complete and file the
Application for \\'aiver of Court Fees and Costs (Form FW-001).)
6i)n Lawyeds Fees and Costs
I ask the court to order pay'meni of my:
a. I Lat*]er's f:es
c. il Out-of-pocket expenses
The amounts requested are:
Item Amount Item Amount
I $

S $

$
$

X Check here if you need more space. Attach a sheet of paper and write "CH-100, item l8-Lawyer's Fees and
Cosx" at the top of the page

@ Additiona! Relief
I ask the court for additional relief as may be proper.

@ Number of oases attached to this form. if anv:

Date:

Lawyer's name Lawyer's signature

I declare under penalty of perjury under the laws of the State of California that the information above and on
all attachments is true and correct.
D"t". ll 22 /0
Cf(tu 6 sFt4q '
Type or print your name

-
"r -: -r, 1 2007 GH-l 00, Page 4 of 4
Request for Orders to Stop Harassment
-

(Civil Harasslnent)
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