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CH-100 Request for Orders to Stop Harassment (California)

This form is a request to stop harassment order in California. The form provided here is simply a sample of what the actual Form CH-100 looks like.

Judicial Council of California, www.courtinfo.ca.gov
Revised January 1, 2005, Mandatory Form


CH-100 Request for Orders to Stop Harassment

----------------------------

Clerk stamps date here when form is filed.

Fill in court name and street address:

Superior Court of California, County of __________________________

Court fills in case number when form is filed.

Case Number: __________________________


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1. Your name (person asking for protection): ________________________

Your address (skip this if you have a lawyer):
(If you want your address to be private, give a mailing address instead):

__________________________

City: __________________________

State: __________________________

Zip: __________________________

Your telephone number (optional): ( _____ ) __________________________

Your lawyer (if you have one):

Name __________________________

Address __________________________

Telephone number __________________________

State Bar number:

2. Name of person you want protection from: _______________________

Describe the person:

Sex: ____ M ____ F

Weight: __________________________

Height: __________________________

Race: __________________________

Hair Color: __________________________

Eye Color: __________________________

Age: __________________________

Date of Birth: __________________________

Home Address (if you know): __________________________

City: __________________________

State: __________________________

Zip: __________________________

Work Address (if you know): __________________________

City: __________________________

State: __________________________

Zip: __________________________

3. Besides you, who needs protection? (Family or household members)

Full Name __________________________

Sex __________________________

Age __________________________

Lives with you? ____ Yes ____ No

How are they related to you? __________________________


Full Name __________________________

Sex __________________________

Age __________________________

Lives with you? ____ Yes ____ No

How are they related to you? __________________________

____ 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.

4. Why are you filing in this court? (Check all that apply):

____ The person in 2 lives in this county.

____ I was hurt (physically or emotionally) by the person in 2 here.

____ Other (specify): __________________________

How do you know the person in 2? (Describe): _______________________

6. Describe how the person in 2 has harassed you: ___________________

a. Date of most recent harassment: ______________________

b. Who was there? ______________________

c. Did the person in 2 commit any acts of violence or threaten to commit any acts of violence against you?

____ Yes ____ No

If yes, describe those acts or threats: __________________________

d. Did the person in 2 engage in a course of conduct that harassed you and caused substantial emotional distress? ____ Yes ____ No

If yes, describe: __________________________

e. Did the conduct of the person in described above seriously alarm, annoy, or harass you? ____ Yes ____ No

____ Check here if you need more space. Attach a sheet of paper and write "CH-100, item 6¬¬Describe Harassment" at the top of the page.

Check the orders you want

7. Personal Conduct Order

I ask the court to order the person in 2 to NOT do the following things to me or anyone listed in 3:

a. ____ Harass, attack, strike, threaten, assault (sexually or otherwise), hit, follow, stalk, destroy personal property, keep under surveillance, or block movements.

b. ____ Contact (either directly or indirectly), or telephone, or send messages or mail or e-mail.

8. Stay-Away Order

I ask the court to order the person in 2 to stay at least (specify): ______________ yards away from me and the people listed in 3 and the places listed below: (Check all that apply):

a. ____ My home

b. ____ My job or workplace

c. ____ My children's school or child care

d. ____ My vehicle

e. ____ Other (specify): __________________________

If the court orders the person in 2 to stay away from all the places listed above, will that person still be able to get to his or her home, school, or job? ____ Yes ____ No

If no, explain: __________________________

9. Others to Be Protected

Should the other people listed in 3 also be covered by the orders described above?

____ Yes ____ No ____ Does not apply

If yes, explain: __________________________

10. Order About Guns or Other Firearms

I ask the court to order the person in 2 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 controls.

11. Other Orders

I ask the court to order the person in 2 to (specify):

__________________________

__________________________

12. Temporary Orders

Do you want the court to make orders now on the matters listed in 7, through 11 that will last until the hearing? ____ Yes ____ No

If yes, explain why you need these orders right now:

__________________________

__________________________

____ Check here if you need more space. Attach a sheet of paper and write "CH-100, item 12 Temporary Orders" at the top of the page.

13. Delivery of Orders to Law Enforcement

My lawyer or I will give copies of the orders to the following law enforcement agencies:

Name of Agency: __________________________

Address: __________________________

City: __________________________

State: __________________________

Zip: __________________________


Name of Agency: __________________________

Address: __________________________

City: __________________________

State: __________________________

Zip: __________________________

14. Other Court Cases

Have you ever asked any court for other restraining orders against the person in 2? ____ Yes ____ No

If yes, specify the counties and case numbers if you know them:

__________________________

__________________________

15. Time for Service

You must have your papers personally served on (notify) the person in 2 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-130 may be used to show the court that the papers have been served.) If your papers cannot be served at least 5 days before the hearing and you need more time, explain why:

__________________________

__________________________

16. No Fee for Filing

I ask the court to waive the filing fee because the person in 2 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.

17. No Fee to Serve Orders

I ask the court to order the sheriff or marshal to serve (notify) the person in 2 about the orders for free because that person has stalked me or threatened me with sexual assault.

(To get free service of the court's orders without paying a fee, you must fill out and file the Request and Order for Free Service of Restraining Order (Form CH-101), and if you qualify for a fee waiver, you must also fill out and file the Application for Waiver of Court Fees and Costs (Form 982(a)(17).)

18. Lawyer's Fees and Costs

I ask the court to order payment of my:

a. ____ Lawyer's fees

b. ____ Out-of-pocket expenses

The amounts requested are:

Item ____________________________

Amount $____________________

Item ____________________________

Amount $____________________

Item ____________________________

Amount $____________________

____ Check here if you need more space. Attach a sheet of paper and write "CH-100, item 18 Lawyer's Fees and Costs" at the top of the page.

19. Additional Relief

I ask the court for additional relief as may be proper.

Number of pages attached to this form, if any: ____________


Date: ____________________________

Attorney's name ____________________________

Attorney's signature ____________________________


I declare under penalty of perjury under the laws of the State of California that the information above is true and correct.

Date: ____________________________

Type or print your name ____________________________

Sign your name ____________________________

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