*NOTICE TO ALL PERSONS APPLYING FOR A PROTECTIVE

*NOTICE TO ALL PERSONS APPLYING FOR A PROTECTIVE ORDER*

PROTECTIVE ORDER COSTS

ALTHOUGH NO COURT COSTS ARE DUE AT THE TIME OF FILING,

COURT COSTS ARE STILL INCURRED. PROTECTIVE ORDER COURT

COSTS AVERAGE BETWEEN $300.00 AND $800.00. YOU MAY BE

LIABLE FOR THESE COSTS. IF YOU DO NOT SHOW UP AND YOUR

CASE IS DISMISSED AT THE TIME OF HEARING, YOU MAY BE CAST

WITH COURT COSTS. IF THERE IS A CONTESTED HEARING HELD,

THE COURT WILL DETERMINE WHO IS RESPONSIBLE FOR COSTS.

I HAVE READ THE ABOVE AND UNDERSTAND MY RESPONSIBILITY

AS TO THE COURT COSTS OF THE PROTECTIVE ORDER.

___________________________ ________________________

SIGNATURE DATE

==========================================================

APPLICANT MUST READ AND INITIAL EACH ENUMERATED

STATEMENT OF THIS FORM BEFORE APPLYING FOR A PROTECTIVE ORDER

_____ 1) Has a protective order request been made involving any party listed in this

protective order in any court? (circle one) YES NO

If yes, where _____________ , when ___________ and status ______________________.

____ 2) By filing a petition for a protective order, you understand you are making a

serious accusation to the court about the behavior and circumstances of another person.

____ 3) By signing the petition for a protective order, you are stating under oath to

the court that the allegations contained in your petition are true and correct.

____ 4) The petition you are about to file is a legal document that may result in court

action. As with all legal documents, you are advised to consult an attorney before filing.

____ 5) After filing this petition, the court may grant your request for a temporary

restraining order. You will be required to come to court and prove the accusations made in

your petition in order to obtain a protective order.

____ 6) It is your responsibility to present the evidence necessary to obtain the relief

sought. You are strongly advised to have an attorney represent you when you come to

court. If you do not have an attorney at the time, the judge WILL NOT act as your attorney.

____7) If you cannot prove the accusations you have made, the protective order will

be dismissed.

____8) Any false statement under oath contained in the affidavit shall constitute

perjury and shall be punishable by a fine of not more than one thousand dollars, or by

imprisonment, with or without hard labor, for more than five years, or both. (La. R.S.

46:2134)

By signing this form, applicant certifies that she/he has read and understands the forgoing

statements.

______________________________

Signature of Applicant

LPOR D

Page 1 of 7 v.14

_________________________________________

PETITIONER

V.

_________________________________________

DEFENDANT

_________________________________________

Parent/Guardian name if defendant is a minor

__________________________________ COURT

PARISH/CITY OF __________________________

STATE OF LOUISIANA

DIVISION: _______ NUMBER: ________________

FILED: _____________ CLERK: ______________

PETITION FOR PROTECTION FROM ABUSE

Pursuant to La. R.S. 46:2171 et seq. or La. R.S. 46:2181 et seq.

This petition is: Initial Petition Supplemental and Amending Petition

The petition of __________________________________________________, born _______________________________

your name month/day/year

a resident of the State of Louisiana, respectfully represents:

Paragraph 1: Petitioner/Protected Person(s)

Petitioner files this petition on behalf of:

a. ____ Petitioner, and/or

b. ____ Minor child(ren) as follows: (Name, Date of Birth, Relationship to Petitioner)

__________________________________

______________

____________________________________

__________________________________

______________

____________________________________

__________________________________

______________

____________________________________

__________________________________

______________

____________________________________

__________________________________

______________

____________________________________

__________________________________

______________

____________________________________

c. ____ Alleged incompetent as follows: (Name, Date of Birth, Relationship to Petitioner)

__________________________________

______________

____________________________________

__________________________________

______________

____________________________________

Paragraph 2: Protected Person(s) Address

a.

____

Petitioner requests that his/her address, or that of the minor child(ren) or alleged incompetent, remain

confidential to the court and files the address pursuant to La. R.S. 46:2134(B).

(Ask clerk of court for the Confidential Address Form.)

OR

b.

____

Petitioner’s current address:

_______________________________________________________________________________________

No. & Street Apt. No.

_______________________________________________________________________________________

City State Zip Code

c.

____

The minor child’s or alleged incompetent’s current address:

_______________________________________________________________________________________

No. & Street Apt. No.

_______________________________________________________________________________________

City State Zip Code

Paragraph 3: Special Requests

a.

____

Petitioner requests interpreter service, for:

 self/protected person, in following language: ______________________________

 witness(es), in following language: _________________________________

26th JUDICIAL DISTRICT

BOSSIER / BENTON

PO

LPOR D

Page 2 of 7 v.14

b.

____

Petitioner requests criminal history record from sheriff for:

 defendant

 witness(es) (see information on Addendum, page 8)

Paragraph 4: Defendant Address

_________________________________________, defendant, resides in ______________________________ Parish at

Abuser’s Name

__________________________________________________________________________________________________

No. & Street Apt. No. State Zip Code

Paragraph 5: Venue

This Court is the proper venue for this action because:

The defendant resides in _______________________________ Parish.

____ The stalking/sexual assault occurred in _______________________________ Parish.

____ The protected person(s) resides in _______________________________ Parish.

(Do not fill this out if address is to remain confidential.)

Paragraph 6: Relationship

The defendant is an acquaintance of or stranger/unknown to the protected person(s).

Paragraph 7: Description of stalking/sexual assault

a. Stalking (La. R.S. 46:2171 et seq.): Defendant intentionally and repeatedly engaged in the following behavior(s) which

caused the protected person to feel alarmed or to suffer emotional distress:

___

Followed protected person(s)

___

Implied or threatened protected person(s) with bodily injury

___

Harassed protected person(s)

___

Implied or threatened protected person(s)’ life

___

Uninvited presence at protected person(s)’ home

___

Used tracking device to monitor protected person(s)

___

Uninvited presence at protected person(s)’ workplace

___

Stalked, harmed/threatened to harm protected person(s) or

member of protected person(s)’ family or acquaintance of

protected person(s)

___

Uninvited presence at protected person(s)’ school

___

Uninvited presence at other places

___

Implied or threatened protected person(s) with kidnapping

___

Made/sent telephone calls, texts, emails or other

electronic communications to protected person(s)

___

Implied or threatened protected person(s) with sexual

assault

___

Sent messages via a third party, letters, pictures, public

posts to social media

___

Possessed a dangerous weapon during any of the foregoing

behaviors

___

Sent unwanted gifts to protected person(s)

___

Threatened protected person(s) with a dangerous weapon

___

Other:________________________________________________________________________________________________

_____________________________________________________________________________________________________

b. Sexual assault (La. R.S. 46:2181 et seq.): Defendant intentionally assaulted the protected person in the following manner:

___

Touched the protected person’s genitals, anus, breasts or buttocks (either directly or through clothing) using defendant’s body

part(s) or other objects, without consent.

___

Forced the protected person to touch the defendant’s genitals, anus, breasts or buttocks (either directly or through clothing)

using protected person’s body part(s) or other objects.

___

Penetrated the protected person’s vagina or anus using defendant’s body part(s) or other objects, without consent.

___

Forced the protected person to penetrate the defendant’s vagina or anus, using protected person’s body part(s) or other

objects.

___

Displayed genitals, anus, and/or female breast nipples to protected person without consent, in a public place or prison/jail.

___

Deceived the protected person into engaging in anal, oral or vaginal intercourse with the defendant by misrepresenting

themselves as someone else known to the protected person.

___

Sent an electronic communication, letter, photograph, or drawing containing sexually explicit materials or content to the

protected person without consent.

LPOR D

Page 3 of 7 v.14

___

Exposed the protected person to the HIV/AIDS virus through sexual contact without the knowing and lawful consent of the

protected person.

___

Viewed or spied on the protected person at a private residence without consent for defendant’s sexual gratification.

___

Used an image or video recording device to view or observe the protected person without consent for a lewd or lascivious

purpose.

___

Electronically transferred an image or video of the protected person obtained by the above without the consent of the protected

person.

___

Gave a drug, narcotic, anesthetic, intoxicant agent or other controlled dangerous substance to the protected person without

her/his consent.

___

Possessed a dangerous weapon at the time of any of the foregoing behaviors.

___

Threatened the protected person with a dangerous weapon during any of the foregoing behaviors.

___

Other:

________________________________________________________________________________________________

c. The facts and circumstances of stalking or sexual assault are as follows:

The most recent incident of stalking or sexual assault which caused petitioner to file this petition happened on or about

_______________________ (date) at which time the defendant did:

Past incidents: __________________________________________________________________________________

LPOR D

Page 4 of 7 v.14

Paragraph 8: Requests for relief

Because of the immediate and present danger of stalking, or sexual assault, petitioner requests that an ex parte Temporary

Restraining Order be issued immediately without bond:

_____ a.

prohibiting defendant from abusing, harassing, assaulting, stalking, following, tracking, monitoring, or threatening

the protected person(s) in any manner whatsoever. This prohibition includes the use, attempted use, or

threatened use of physical force that would reasonably be expected to cause bodily injury.

_____ b.

prohibiting the defendant from contacting the protected person(s) personally, through a third party, or via public

posting, by any means, including written, telephone, or electronic (text, email, messaging, or social media)

communication, or sending gifts to the protected person(s).

_____ c.

prohibiting defendant from going within one hundred (100) yards of the residence, apartment complex, or

multiple family dwelling of the protected person(s) located at:

_____ d.

ordering the defendant to stay away from the protected person(s)’ place of employment/school and not to

interfere in any manner with such employment/school located at:

_________________________________________________________________________________________

Employment/School Address City State Zip Code

___________________________________________________________________________________________________

Employment/School Address City State Zip Code

_____ e.

ordering the defendant not to damage any belongings of the protected person(s), not to shut off any utilities,

telephone service, or mail delivery to the protected person(s), or in any way interfere with the living conditions of

the protected person(s).

_____ f.

granting the petitioner or protected person(s) the use of the residence located at:

_________________________________________________________________________________________

No. & Street Apt. No. City State Zip Code

to the exclusion of defendant by evicting defendant and ordering the defendant to surrender any keys to that

residence to the petitioner, and ordering __________________________________ (Sheriff’s office) to evict the

defendant.

Said residence is:

____ jointly owned by defendant and petitioner or protected person(s).

____ jointly leased by defendant and petitioner or protected person(s).

____ solely owned or leased by petitioner or protected person(s).

Presently occupied by _____________________________________.

_____ g.

granting petitioner or protected person(s) possession of the following property (including pets or other animals)

solely owned or leased by petitioner or protected person(s) (state location of each by street address and

who is presently in possession).

_________________________________________________________________________________________

granting petitioner or protected person(s) the exclusive use and possession of the following property (including

pets or other animals) jointly owned or leased by petitioner or protected person(s) (state location of each

by street address and who is presently in possession).

_________________________________________________________________________________________

for the following reasons: ____________________________________________________________________

_________________________________________________________________________________________

LPOR D

Page 5 of 7 v.14

And ordering ____________________________________ (Sheriff’s office) to accompany petitioner to where the

above listed property is located to allow petitioner to take possession.

_____ h.

prohibiting either party from transferring, encumbering, or otherwise disposing of property jointly owned or

leased, except in the normal course of business or necessary for the support of the petitioner and/or the minor

child(ren) or alleged incompetent.

_____ i.

allowing ____________________________________ to return to the residence at a date and time to be agreed

upon by petitioner and law enforcement agency, to recover his/her personal clothing and necessities, only if s/he

is accompanied by a law enforcement officer to ensure the protection and safety of the parties. NO FORCED

ENTRY ALLOWED.

_____ j.

ordering a representative of ___________________________________________ (Sheriff’s office) to

accompany _______________________________ to the family residence to recover her/his personal clothing

and necessities.

_____ k.

prohibiting the defendant from contacting protected person(s)’ family members, or individuals with whom

protected person(s) is acquainted.

Paragraph 9: Other Requests

Petitioner desires that a rule issue herein ordering defendant to show cause why the orders requested in Paragraph 8 should

not be made into protective orders, and why defendant should not also be ordered:

___ to seek professional counseling

___ to submit to a medical evaluation and/or a mental health evaluation

___ to pay costs of court in this matter.

___ to pay attorney fees

___ to pay evaluation fees

___ to pay expert witness fees

___ to pay cost of medical / psychological care for the protected person(s), necessitated by the stalking or sexual assault

___ to vacate the residence or household, thereby granting petitioner possession thereof

___ other: _______________________________________________________________________________________

PRAYER

WHEREFORE, petitioner prays that service and citation issue herein, and that: (check all that apply)

___ orders appointing an interpreter be granted ex parte.

___ orders authorizing criminal history records be granted ex parte.

___ orders requested in Paragraph 8 be granted ex parte.

___ a rule issue to show cause why protective orders as requested in Paragraph 9 should not be granted.

___ defendant be cast with costs.

___ defendant be advised of penalties for violating Stalking or Sexual Assault Prevention Orders.

___ all other equitable relief as the court deems proper and necessary.

Respectfully submitted by ______________________________________

PETITIONER, IN PROPER PERSON

______________________________________ __________________________________ ______________________

ATTORNEY Signature Print Name La. Bar Roll No.

____________________ ____________________________________________________________________________

Phone No. Physical Address

___________________________________________________________________________________________________

Alternate Address (for service)

PLEASE SERVE DEFENDANT: ___________________________________________________ personally at his/her home or

place of employment at the following address:

OR

LPOR D

Page 6 of 7 v.14

AFFIRMATION

STATE OF LOUISIANA

PARISH OF _______________________________________

I am the petitioner in this Petition for Protection from Stalking or Sexual Abuse; I have read the allegations

contained therein and declared them to be true and correct to the best of my knowledge, information, and belief.

Further I believe that the defendant poses a threat to my safety and/or to the child(ren) or to others for whom I

have requested relief.

I am aware that any false statement made under oath contained in the foregoing petition and this affirmation may

constitute perjury pursuant to R.S. 14:123.

I have made this affirmation before the witness who signed below on _____________________ (Date).

_______________________________________

PETITIONER SIGNATURE

PRINTED NAME OF WITNESS: _____________________________________________

________________________________________

WITNESS SIGNATURE

LPOR D

Page 7 of 7 v.14

ADDENDUM

Fill out the following ONLY if requesting an order for witness criminal history records in Paragraph 3 on page 1 of this

petition:

Identifying information for witness criminal history record:

Full legal name

Date

of birth

Address*

Race*

Sex*

Other identifiers*

*optional

Docket No. ___________________

Page 1 of 7 LPOR 1

v.14

LOUISIANA UNIFORM ABUSE PREVENTION ORDER

Order of Protection

Temporary Restraining Order

Docket No.

Court: _____________________________ Div.:_________

City/Parish State

Filed: _______________ Clerk: _____________________

PETITIONER

PETITIONER IDENTIFIERS

First Middle Last

Date of birth Race Sex: Fe Sex: M

Protected person is: Petitioner Other(s) List other(s) name & date of birth:

V.

DEFENDANT NAME AND ADDRESS

DEFENDANT IDENTIFIERS

First Middle Last

Name of minor defendant’s parent or guardian

Defendant’s Alias: _____________________________

______________________________

No. & Street Apt. No.

______________________________

City State Zip Code

SEX

RACE

DOB

HT

WT

EYES

HAIR

SOCIAL SECURITY #

DRIVER’S LICENSE #

STATE

EXP DATE

THE COURT HEREBY FINDS:

That is has jurisdiction over the parties and subject matter, and the defendant has been or will be provided with reasonable

notice and opportunity to be heard. Additional findings of this court are as set forth on the following pages.

THE COURT HEREBY ORDERS:

That the above-named defendant be restrained from committing further acts of abuse or threats of abuse, stalking or sexual

assault. Additional terms of this order are as set forth on the following pages.

EXPIRATION:

This order shall be effective through 11:59 PM on

(month/day/year)

ENFORCEMENT:

This order shall be enforced, even without registration, by the courts of any state, the District of Columbia, any U.S. Territory,

and may be enforced by Tribal Lands (18 U.S.C. Section 2265).

WARNINGS TO DEFENDANT:

Crossing state, territorial, or tribal boundaries to violate this order may result in federal imprisonment (18 U.S.C. Section

2262).

Federal law provides penalties for possessing, transporting, shipping, or receiving any firearm or ammunition (19 U.S.C.

Section 922[g][8]). See further notice on page 6 of this Order.

ONLY THE COURT CAN CHANGE THIS ORDER.

Louisiana

26th JUDICIAL DISTRICT

PO

BENTON / BOSSIER

Docket No. ___________________

Page 2 of 7 LPOR 1

v.14

LOUISIANA UNIFORM ABUSE PREVENTION ORDER

TEMPORARY RESTRAINING ORDER

Pursuant to:

 La. R.S. 46:2131 et seq. (Domestic Abuse)

 La. R.S. 46:2171 et seq. (Non-intimate stalking)

46:2171 and

46:2181 valid for

relationships in

Box C below ONLY

 La. R.S. 46:2151 (Dating Violence)

 La. R.S. 46:2181 et seq. (Non-intimate sexual assault)

 La. Ch. C. Article 1564 et seq. (Children’s Code Domestic Abuse)

PETITIONER ________________________________________________ Protected person is:  Petitioner  other(s)

V.

DEFENDANT __________________________________________________________________________________________

The protected person(s) is related to the defendant as: (check all that apply)

A

1. current or former spouse

2. current or former intimate cohabitant

3. child, stepchild, or foster child

4. child of defendant’s current or former intimate partner

5. protected person and defendant have a child(ren) in

common

B

1. current or former dating partner

2. parent, stepparent, or foster parent

3. grandparent or other ascendant

4. grandchild or other descendant

5. child currently or formerly living with defendant

C

Select ONLY if statute 46:2171 or 46:2181 is

marked above

1. stranger/no relationship

2. acquaintance

D

FINDING: Domestic Abuse or Dating Violence

THE COURT FINDS THAT THE ALLEGATIONS PRESENTED CONSTITUTE AN IMMEDIATE AND PRESENT

DANGER TO THE PHYSICAL SAFETY OF THE PROTECTED PERSON(S).

FINDING: Stalking

THE COURT FINDS THAT THE ALLEGATIONS PRESENTED CONSTITUTE AN IMMEDIATE AND PRESENT

DANGER OF STALKING.

FINDING: Sexual Assault

THE COURT FINDS THAT THE ALLEGATIONS PRESENTED CONSTITUTE A SEXUAL ASSAULT.

THUS, THE COURT ISSUES THE FOLLOWING ORDERS, WITHOUT A HEARING:

E

The court orders interpreter services

The court orders the sheriff to provide criminal history

records of defendant and/or witnesses

IT IS ORDERED THAT THE DEFENDANT BE SERVED WITH A COPY OF THIS ORDER.

Docket No. ___________________

Page 3 of 7 LPOR 1

v.14

DOMESTIC ABUSE, DATING VIOLENCE, STALKING OR SEXUAL ASSAULT

ONLY ORDERS INITIALED BY A JUDGE SHALL APPLY

_____ 1.

THE DEFENDANT IS ORDERED NOT TO abuse, harass, assault, stalk, follow, track, monitor, or threaten the

protected person(s) in any manner whatsoever. This prohibition includes the use, attempted use, or threatened

use of physical force that would reasonably be expected to cause bodily injury.

_____ 2.

THE DEFENDANT IS ORDERED NOT TO contact the protected person(s) personally, through a third party,

or via public posting, by any means, including written, telephone, or electronic (text, email, messaging, or social

media) communication without the express written permission of this court.

Exceptions (if any):_________________________________________________________________________

_________________________________________________________________________________________

_____ 3.

THE DEFENDANT IS ORDERED NOT TO go within _________________________ (distance) of the protected

person(s), without the express written permission of this court.

Exceptions (if any):_________________________________________________________________________

_________________________________________________________________________________________

_____ 4.

THE DEFENDANT IS ORDERED NOT TO go within one hundred (100) yards of the residence, apartment

complex, or multiple family dwelling of the protected person(s).

_________________________________________________________________________________________

No. & Street Apt. No. City State Zip Code

_____ 5.

THE DEFENDANT IS ORDERED TO STAY AWAY from protected person(s)’ place of employment/school and

not to interfere in any manner with such employment/school.

_________________________________________________________________________________________

Employment/School Address City State Zip Code

_________________________________________________________________________________________

Employment/School Address City State Zip Code

_____ 6.

THE DEFENDANT IS ORDERED NOT TO damage any belongings or property of the protected person(s) and

not to shut off any utilities, telephone service, or mail delivery to the protected person(s) or in any way interfere

with the living conditions of the protected person(s).

_____ 7.

THE COURT GRANTS THE PETITIONER or protected person(s) the use of the residence located at:

_________________________________________________________________________________________

No. & Street Apt. No. City State Zip Code

to the exclusion of defendant by evicting defendant. The Court orders the defendant to surrender any keys to

that residence to the petitioner.

_________________________________________________ (Sheriff’s office) is ordered to evict the defendant.

_____ 8.

THE COURT GRANTS THE PETITIONER or protected person(s) the use and possession of the following

property (including pets or other animals) and/or the return of protected person(s) property:

_________________________________________________________________________________________

____ 9.

THE COURT ORDERS a representative of _________________________________________(Sheriff’s office)

to accompany petitioner to obtain property listed in Order No. 8 above.

Docket No. ___________________

Page 4 of 7 LPOR 1

v.14

____ 10.

THE COURT PROHIBITS EITHER PARTY from transferring, encumbering, or otherwise disposing of property

jointly owned or leased, except in the normal course of business or that which is necessary for the support of the

petitioner and/or the minor child(ren).

____ 11.

THE COURT WILL ALLOW ___________________________________ to return to the residence at a date and

time to be agreed upon by petitioner and law enforcement agency to recover his/her personal clothing and

necessities, provided that s/he is accompanied by a law enforcement officer to ensure the protection and safety

of the parties. NO FORCED ENTRY ALLOWED.

____ 12.

THE COURT ORDERS a representative of _________________________________________ (Sheriff’s office)

to accompany _________________________________________________________ to the residence located

at _____________________________________________ to recover her/his personal clothing and necessities.

DOMESTIC ABUSE, DATING VIOLENCE ONLY

ONLY ORDERS INITIALED BY A JUDGE SHALL APPLY

____ 13.

THE COURT GRANTS TEMPORARY CUSTODY of the following child(ren) or alleged incompetent to the

petitioner: (name, date of birth, and relationship to petitioner)

_________________________________________________________________________________________

____ 14.

THE COURT ORDERS a representative of ________________________________________ (Sheriff’s office) to

accompany petitioner to where the minor child(ren) or alleged incompetent mentioned in paragraph above is/are

currently, and to effect petitioner obtaining physical custody of said child(ren) or alleged incompetent.

____ 15.

THE DEFENDANT IS ORDERED NOT TO interfere with the physical custody of the minor child(ren) or alleged

incompetent.

____ 16.

THE DEFENDANT IS ORDERED TO show cause on the below hearing date why s/he should not be evicted from

the solely owned residence or household and the petitioner granted possession.

____ 17.

THE DEFENDANT IS ORDERED TO show cause on the below hearing date why s/he should not be ordered to

pay child support and/or spousal support (alimony) pursuant to Louisiana Law. The court further orders the

defendant to produce at the hearing: most recent income tax returns AND pay stubs or an employer

statement documenting gross income to date for the CURRENT year. If the defendant is self-employed,

income and expense statements shall be produced.

STALKING, SEXUAL ASSAULT ONLY

ONLY ORDERS INITIALED BY A JUDGE SHALL APPLY

____ 18.

THE DEFENDANT IS ORDERED NOT TO contact family members or acquaintances of the protected

person(s).

DOMESTIC ABUSE, DATING VIOLENCE, STALKING OR SEXUAL ASSAULT

ONLY ORDERS INITIALED BY A JUDGE SHALL APPLY

____ 19.

THE DEFENDANT IS ORDERED TO show cause on the below hearing date why s/he should not be ordered to

pay the following:

all court costs attorney fees

evaluation fees expert witness fees

cost of medical and/or psychological care for the petitioner, the minor child(ren), alleged incompetent, and/or

other protected person(s) necessitated by the domestic abuse, dating violence, stalking or sexual assault.

____ 20.

THE DEFENDANT IS ORDERED TO show cause on the below hearing date why s/he should not be ordered to

seek professional counseling, complete a court-monitored domestic abuse intervention program, submit to a

medical evaluation and/or submit to a mental health evaluation.

Docket No. ___________________

Page 5 of 7 LPOR 1

v.14

____ 21.

Other:

_________________________________________________________________________________________

IT IS FURTHER ORDERED THAT DEFENDANT show cause on _________________________ (month/day/year)

at ____ o’clock ____. M. in Courtroom No. _____ of the __________________________________ Court, located

at ________________________________________________ in _____________________________, La., why the

above Temporary Restraining Order and other relief requested should not be made Protective Orders.

Date of Order

Time of Order

Order effective

through

11:59 PM on

_______________________________________________

SIGNATURE OF JUDGE

Order issued ex parte

Order issued after notice and opportunity for hearing

given to defendant

_______________

month/day/year

____________

AM PM

__________________

month/day/year

_____________________________________________

PRINT OR STAMP JUDGE’S NAME

NOTICE: C.C.P. Article 3603.1 - Any person against whom such an order is issued shall be entitled to a court-appointed

attorney if the applicant has likewise been afforded a court-appointed attorney.

NOTICE TO DEFENDANT - VIOLATION OF ORDER:

PURSUANT TO LA. R.S. 14:79, A PERSON WHO VIOLATES THIS ORDER MAY BE ARRESTED, JAILED, AND

PROSECUTED.

PURSUANT TO LA. R.S. 13:4611 AND LA. CH. C. ARTICLE 1571, A PERSON WHO VIOLATES THIS ORDER MAY BE

PUNISHED FOR CONTEMPT OF COURT BY A FINE OF NOT MORE THAN $1,000 OR BY CONFINEMENT IN JAIL FOR AS

LONG AS 6 MONTHS, OR BOTH, AND MAY BE FURTHER PUNISHED UNDER CRIMINAL LAWS OF THE STATE OF

LOUISIANA. THIS ORDER SHALL BE ENFORCED BY ALL LAW ENFORCEMENT OFFICERS AND COURTS OF THE STATE

OF LOUISIANA.

12

P

4A

26th Judicial District

Bossier Parish Courthouse, 204 Burt Blvd.

Benton

Docket No. ___________________

Page 6 of 7 LPOR 1

v.14

NOTICE TO DEFENDANT – FIREARM POSSESSION (Domestic abuse or dating violence ONLY):

AS A RESULT OF THIS ORDER, IT MAY BE UNLAWFUL FOR YOU TO POSSESS, RECEIVE, SHIP,

TRANSPORT OR PURCHASE A FIREARM, INCLUDING A RIFLE, PISTOL, OR REVOLVER, OR

AMMUNITION, FOR THE DURATION OF THIS ORDER PURSUANT TO STATE AND/OR FEDERAL

LAWS. See below.

If you have any questions whether these laws make it illegal for you to possess or purchase a firearm or

ammunition, consult an attorney.

Federal law: 18 U.S.C. 922 (g)(8) prohibits a defendant from purchasing, possessing, shipping, transporting, or receiving

firearms or ammunition* for the duration of this order if the following conditions apply:

-

Protected person(s) relationship to defendant is checked in Box A on page 2 of this order

AND

Notice and opportunity for a hearing provided

AND

EITHER Judicial finding of credible threat, OR

Certain behaviors are prohibited (item 1 on page 3 of this order is initialed)

*Under 18 U.S.C. 921 the term “firearm” means (A) any weapon (including a starter gun) which will or is designed to or may readily be

converted to expel a projectile by the action of an explosive; (B) the frame or receiver of any such weapon; (C) any firearm muffler or firearm

silencer; or (D) any destructive device. Such term does not include an antique firearm. The term “ammunition” means ammunition or

cartridge cases, primers, bullets, or propellant powder designed for use in any firearm.

NOTICE TO DEFENDANT – FIREARM TRANSFER AND SUSPENSION OF CONCEALED HANDGUN PERMIT

(Domestic abuse or dating violence ONLY)

IF A PROTECTIVE ORDER IS ISSUED AGAINST YOU, YOU MAY BE REQUIRED TO TRANSFER ANY AND

ALL FIREARMS OWNED OR POSSESSED BY YOU AND SURRENDER YOUR CONCEALED HANDGUN

PERMIT. AS YOU MAY ALSO BE REQUIRED TO STATE UNDER OATH THE NUMBER OF FIREARMS

YOU POSSESS, THE TYPE AND LOCATION OF EACH AND COMPLETE A FIREARMS INFORMATION

FORM VERIFYING SUCH, BRING THIS INFORMATION TO THE HEARING. THE INFORMATION MAY BE

REQUIRED EVEN IF YOU TRANSFERRED THE FIREARMS PRIOR TO THE TRANSFER ORDER.

Louisiana law: C.Cr.P. Art. 1001 et seq. requires the transfer of all firearms owned or possessed and the suspension of a

concealed handgun permit:

- When a person is subject to a permanent injunction or a protective order pursuant to a court-approved consent agreement

or pursuant to the provisions of R.S. 9:361 et seq., R.S. 9:372, R.S. 46:2136, 2151, or 2173, Children's Code Article 1570,

Code of Civil Procedure Article 3607.1, or C.Cr.P. Articles 30, 320, or 871.1.

OR

- When a person is subject to a Uniform Abuse Prevention Order that includes terms prohibiting possession of a firearm or

carrying a concealed weapon.

FULL FAITH AND CREDIT pursuant to 18 U.S.C. § 2265

The issuing court certifies that it has jurisdiction over the parties and the subject matter under the laws of the State of

Louisiana; that the defendant was given reasonable notice and an opportunity to be heard sufficient to protect the defendant’s

right to due process before this order was issued; or if the order was issued ex parte, the court ordered that the defendant be

given reasonable notice and an opportunity to be heard within the time required by the laws of the State of Louisiana, and in

any event, within a reasonable time after the order was issued, sufficient to protect the defendant’s due process rights.

THIS ORDER SHALL BE PRESUMED VALID AND ENFORCEABLE IN ALL 50 STATES, THE DISTRICT OF

COLUMBIA, TRIBAL LANDS, U.S. TERRITORIES, AND COMMONWEALTHS.

__________________________________________________

SIGNATURE OF JUDGE

__________________________________________________

PRINT OR STAMP JUDGE’S NAME

Docket No. ___________________

Page 7 of 7 LPOR 1

v.14

NOTICE TO LAW ENFORCEMENT

Pursuant to La. R.S. 14:79, the crime of violation of protective orders – you shall use every reasonable means,

including but not limited to immediate arrest of the violator, to enforce this order. Further, you shall at a

minimum issue a summons to the person in violation.

Pursuant to La. R.S. 46:2140(A), if you have reason to believe that a family or household member or dating

partner has been abused AND the abusing party is in violation of this order, you SHALL immediately arrest the

abusing party.

If the expiration date of this order falls on or within five (5) days of the conclusion of a declared state of

emergency, this order/injunction shall be enforced throughout that time period.

DEFENDANT WAS SERVED AT CLOSE OF HEARING.

Date ______________________________ Clerk _____________________________________________________

FAXED or ELECTRONICALLY TRANSMITTED TO LOUISIANA PROTECTIVE ORDER REGISTRY

Date ______________________________ Clerk _____________________________________________________

FAX COMPLETED ORDERS TO 888-568-4558

Copies to: 1) Court file 2) Petitioner/protected person(s) 3) Defendant 4) Chief Law Enforcement Official of the parish where the

protected person(s) resides 5) Louisiana Protective Order Registry.

Page 1 of 1 LPOR H

v.14

INFORMATION FOR SERVICE OF PROCESS

PROVIDED BY PETITIONER/PETITIONER-IN-RECONVENTION

PLEASE PROVIDE AS MUCH INFORMATION AS POSSIBLE. THIS INFORMATION WILL HELP LAW ENFORCEMENT LOCATE

DEFENDANT (or DEFENDANT-IN-RECONVENTION) TO SERVE A COPY OF THE PETITION AND TEMPORARY

RESTRAINING ORDER (IF ISSUED). THE FOLLOWING INFORMATION IS NEEDED ON THE DEFENDANT (or DEFENDANT-

IN-RECONVENTION).

NAME ______________________________________________________________________________________________________

Name of minor defendant’s (or defendant-in-reconvention’s) parent or guardian: ____________________________________________

OTHER NAMES USED ________________________________________________________________________________________

DATE OF BIRTH ______________________ (month/day/year) SOCIAL SECURITY # __________________________________

DRIVERS LICENSE # ___________________________________ STATE ______ EXP. DATE ________________________

HOME ADDRESS ________________________________________________________________________________________

No. & Street Apt. No.

__________________________________________________________ TEL. NO. _____________________

City State Zip Code

WORK ADDRESS ________________________________________________________________________________________

Name of employer

________________________________________________________________________________________

No. & Street Apt. No.

_____________________________________________________ DEPARTMENT ____________________

City State Zip Code

TEL NO. ____________________ WORK DAYS/HOURS _________________________________________

PHYSICAL DESCRIPTION: □ MALE □ FEMALE RACE ____________

EYE COLOR ______________ HAIR COLOR ___________________ HEIGHT _____________ WEIGHT _________________

DISTINGUISHING FEATURES (scars, tattoos, facial hair, etc.)______________________________________________________

_______________________________________________________________________________________________________

MOTOR VEHICLE:

LICENSE PLATE # ________________________ YEAR ________ MAKE ____________________ COLOR ________________

DOES THE DEFENDANT (or DEFENDANT-IN-RECONVENTION):

HAVE A HISTORY OF VIOLENCE TOWARDS OTHERS (OTHER THAN VICTIM)?

□YES

□ NO

HAVE A HISTORY OF USING/ABUSING DRUGS OR ALCOHOL?

□ YES

□ NO

CARRY A WEAPON?

□YES

□ NO

IF YES, WHAT KIND OF WEAPON? _____________________________________________________________________

__________________________________________________________________________________________________

OTHER PLACES AND TIMES S/HE MAY BE FOUND: (Friends, relatives, bars, hangouts)

___________________________________________________________________________________________________________

DEFENDANT/DEFENDANT-IN-RECONVENTION CURRENTLY INCARCERATED

Where: _____________________________________________________________________________________________

DEFENDANT/DEFENDANT-IN-RECONVENTION CURRENTLY ON PROBATION/PAROLE

Probation or parole officer/department:_____________________________________________________________________

ANY OTHER INFORMATION WHICH MAY BE HELPFUL: ____________________________________________________________

____________________________________________________________________________________________________________

____________________ ____________________________________________________

Date Petitioner’s / Petitioner-in-Reconvention’s Signature