Step 2 of 3 — What happened and what you need

This is the most important part of the form. Tell the judge what happened and what orders you need to be safe. Write it in your own words — there's no wrong way to say it.

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What protections do you need?

Check everything that applies. You can ask for more than one.

No contact

They must stop all contact — calls, texts, emails, social media, through other people. This is the most common order.

Stay away

They must keep a set distance from you, your home, your workplace, your children's school. You'll set the distance below.

Move out

They must leave your shared home, even if their name is on the lease or mortgage. A judge can order this in emergencies.

Stay-away distance (yards)

100 yards is standard. Ask for more if needed.

Date of the most recent incident

What exactly do you need them to stop doing?

Be as specific as possible. Some examples of what to include:

No calling, texting, or messaging you directly or through others
No coming near your home, your car, your workplace, your children's school
No threatening, harassing, stalking, or disturbing your peace
No owning or possessing guns or other weapons
Anything else specific to your situation

What you want the court to order (your words)

What happened most recently?

Describe the most recent incident in as much detail as you can. The judge will read this first.

When did it happen? (include the date and approximate time)
Where were you? (home, car, phone call, etc.)
What exactly did they do or say?
Were you injured? Was anyone else present?
Did you call the police? Was a report filed?

Most recent incident (write it like you're telling a friend)

Has this happened before?

If there have been other incidents, describe them here. This shows the judge the full picture, not just the most recent event.

Include dates if you remember them (approximate is fine)
Describe any injuries, medical visits, or police reports
Note any escalation you've seen — things getting worse over time
Leave blank if this is the first incident

Prior incidents and pattern (if any)

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