The undersigned, upon oath, states:___________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
The Respondent's physical address is:______________________________________________________
The Respondent's work address is:________________________________________________________
The Respondent's work hours and phone#__________________________________________________
I SWEAR OR AFFIRM UNDER PENALTY OF PERJURY THAT THE FACTS SET FORTH ABOVE ARE TRUE TO THE
BEST OF MY INFORMATION AND BELIEF. I UNDERSTAND THAT IT IS A CRIMINAL OFFENSE SUBJECT TO THE
PENALTY OF IMPRISONMENT TO MAKE A FALSE STATEMENT IN A SWORN DOCUMENT.
______________________________
Affiant's Signature
______________________________
______________________________
______________________________
(address & phone)
-------------------------------------------------------------------------------------------------------------------
Reviewed by ________________________
Date ________________________
No Action Taken: ____________________
Referred to Special Commissioner ___________
Referred to Districk Judge: _____________
Set for Hearing __________________________
The Affidavit Restraining order up above is only here as a sample of what the real thing
looks like. If you are in need of getting a Restraining order please contact your local
Domestic Violence Shelter, Police Station, and the Municipal Court.
Created on: March 10, 1999
Last Modified:
lacasa@zianet.com
