Worksheet for the Harassment and/or Stalking Petition · 2020. 7. 28. · you complete the...

Worksheet for Harassment/Stalking Petition of 2 UHST 2.0250 (06/2014) RCW 10.14.800

Worksheet for the Harassment and/or Stalking Petition There are several different kinds of protection orders. This worksheet is designed to help you complete a petition for Harassment Orders and/or Stalking Protection Orders.

If you qualify for a Domestic Violence Protection order, this is not the correct form to complete. To help you figure out which order you may be able to get, read the 2 options in the table below. Each option generally describes harassment or stalking conduct. More than one option may apply:

Option 1 (Harassment protection order) Harassment is a pattern of conduct that makes you feel annoyed, alarmed or distressed.

Option 2 (stalking protection order) Stalking is conduct like harassment, following, or monitoring, that makes you feel intimidated, frightened, or threatened and occurs more than once. It may also involve cyberstalking which is transmitting threats or obscene words or pictures to or about you one or more times.

You can find a complete definition of Harassment or Stalking at the end of this worksheet.

You may be eligible for one or both of these orders. The court will determine which order best fits your situation.

Your next step is to fill out the petition. In the petition, you will let the court know what protections you want and explain what the other party has done.

If you think the conduct is harassment, then file your petition in this county if the harassment took place here OR if the person who committed the acts lives in this county.

If you think the conduct is stalking, then file your petition in the county where you reside or where you fled to avoid the stalking contact.

You can start your petition in District Court.• The District Court will transfer your case to Superior Court, or• You can start your petition in Superior Court instead of District CourtIf:1. this case involves title or possession of real property, and the respondent claims an

interest in that property such as ownership or right to occupy.2. the order put limits on the respondent’s care, custody, or control of his or her minor

children.3. you and the respondent are parties in a superior court case.4a. you are alleging harassment by a respondent who is under the age of 18.4b. you are alleging stalking and the petitioner, victim, or respondent is under the age of 18.

Definitions

Unlawful harassment means:

• a knowing and willful course of conduct directed at a specific person which seriouslyalarms, annoys, or harasses, or is detrimental to such person and which serves no

Worksheet for Harassment/Stalking Petition of 2 UHST 2.0250 (06/2014) RCW 10.14.800

legitimate or lawful purpose. o The course of conduct shall be such as would cause a reasonable person to suffer

substantial emotional distress and shall actually cause substantial emotional distress to the petitioner, or when the course of conduct would cause a reasonable parent to fear for the well-being of their child.

“Course of conduct:”

• means a pattern of conduct composed of a series of acts over a period of time, however short, evidencing a continuity of purpose.

• includes, in addition to any other form of communication, contact, or conduct, the sending of an electronic communication. Constitutionally protected activities, including free speech, are not included within the meaning of “course of conduct.”

Stalking Conduct means:

a) any act of stalking as defined under RCW 9A.46.110: A person intentionally and repeatedly harasses or repeatedly follows another person, and

• the person being harassed or followed is placed in fear that the stalker intends to injure the person, another person, or property of the person or of another person. The feeling of fear must be one that a reasonable person in the same situation would experience under all the circumstances; and

• the stalker either: (i) intends to frighten, intimidate, or harass the person; or (ii) knows or reasonably should know that the person is afraid, intimidated, or harassed even if the stalker did not intend to place the person in fear or intimidate or harass the person.

Or

b) any act of cyberstalking as defined under RCW 9.61.260: With intent to harass, intimidate, torment, or embarrass any other person, and under circumstances not constituting telephone harassment, the stalker makes an electronic communication to a person or a third party:

• using any lewd, lascivious, indecent, or obscene words, images, or language, or suggesting the commission of any lewd or lascivious act;

• anonymously or repeatedly whether or not conversation occurs; or • threatening to inflict injury on the person or property of the person called or any member of

his or her family or household. Or

c) any course of conduct involving repeated or continuing contacts, attempts to contact, monitoring, tracking, keeping under observation, or following another [person] that:

• would cause a reasonable person to feel intimidated, frightened, or threatened and that actually causes such a feeling;

• serves no lawful purpose; and • the stalker knows or reasonably should know threatens, frightens, or intimidates the person,

even if the stalker did not intend to intimidate, frighten, or threaten the person.

Washington Pattern Forms Committee

INSTRUCTIONS ON HOW TO FILL OUT THE FORMS FOR

ANTIHARASSMENT

Prepared by the Office of the Administrator for the Courts

Olympia, Washington July 2011

Follow These Instructions Carefully. Please type or print all information requested. These forms are used to get an Antiharassment order of protection. Before you start filling out these forms, make sure you have the right type of forms. Antiharassment: You can get an Antiharassment order of protection if the person you want protection from:

-has acted without legitimate or lawful purpose in a way that shows a continuity of purpose;

-has directed the actions to you or your child; -and the things the person said or did have seriously alarmed, annoyed or harassed you and were the kind of things that would cause a reasonable person substantial emotional distress and have actually caused you substantial emotional distress;

-or the person has done or said things that would cause a reasonable parent to fear for the well being of their child.

Domestic Violence: If the actions involve physical harm, an assault, a sexual assault ,stalking, or threats of physical harm, assault or sexual assault, or stalking and the person you are seeking protection from is a “family or household member,” you need to get a Domestic Violence Order of Protection instead of an Antiharassment Order of Protection. “Family or household member” has a wide meaning and includes current or former husbands, wives, domestic partners, family members, roommates and in some cases people who have dated. Sexual Assault: If the actions involve a sexual assault, and the person who committed the sexual assault is not a family or household member, you need to get a Sexual Assault Protection Order instead of an Antiharassment Order of Protection.

Instructions for Antiharassment Forms (07/2011)

2

Vulnerable Adult: If the petition is being filed by or for a vulnerable adult who has been, or is threatened with being abandoned, abused, neglected or financially exploited, you need to get a Vulnerable Adult protection order instead of an Antiharassment Order of Protection. Get More Information: If you are not sure which petition is best for you, look at all the forms. Each set has a more detailed explanation of whom they apply to. All of the forms are available from the Clerk of the Court, from www.courts.wa.gov/forms, and from www.washingtonlawhelp.org. Where should you file your case? Generally, you must file your case in the district court; but there are some exceptions when you must file your case in superior court:

• the Respondent is under the age of 18 years; • a superior court has exercised or is exercising jurisdiction over a proceeding

involving you and the other party; • the case would interfere with respondent’s care, control or custody of respondent’s

minor child; or • your case involves disputes over title, ownership, or possession of real property;

such as landlord tenant, boundary dispute.

If you are ready to ask for an Antiharassment protection order, continue with the instructions. FORMS NEEDED To begin an action for an order for protection from civil harassment, you will need the following forms: (1) Motion and Declaration for Waiver of Filing Fees and Surcharges - Harassment

- WPF UH-02.0100; (2) Financial Statement – Harassment – WPF UH-02.0110 (3) Order Re Wavier of Filing Fees and Surcharges - Harassment - WPF UH-02.0120;

In this case, you would need to file under a Divorce, Third Party Custody, Parentage, CHINS, or ARY Action.

In this case, you would need to file a Summons and Complaint (or if married to respondent, under a Divorce Action).

http://www.courts.wa.gov/forms


3

(4) Petition For An Order For Protection - Harassment - WPF UH-02.0200; (5) Confidential Information Form - WPF UH 01.0600 (6) Addendum to Confidential Information Form - WPF UH 01.0610 (7) Law Enforcement Information Sheet - All Cases 01.0400; (8) Temporary Protection Order and Notice of Hearing - WPF UH-03.0200; (9) Return of Service (Unlawful Harassment) - WPF UH-04.0110; and (10) Order for Protection from Civil Harassment - WPF UH-04.0500. These forms should be included in this packet. If you are missing any forms or pages inform the clerk. Complete steps 1 through 10 below. ______________________________________________________________________ Step 1 – Fill in the Heading of Each Form. ______________________________________________________________________ You are the Petitioner. The person who is harassing you is the Respondent. Your name and the respondent’s name should be filled in the heading of each form. When you file your papers with the clerk of the court you will be given a case number. Write that case number in the upper right hand corner of every form you complete. ______________________________________________________________________ Step 2 – Waiver of Filing Fees and Surcharges ______________________________________________________________________ If you have funds to pay fees and you are not seeking protection from someone who has stalked, sexually assaulted you or committed acts of domestic violence against you, skip to step 3. (1) Motion and Declaration for Waiver of Filing Fees and Surcharges - Harassment - WPF

UH-02.0100

A. If you cannot pay the fees in your case:

Check paragraph 2.1 to ask the court to waive filing fees and surcharges if you cannot afford to pay them. In the declaration, check the first box in paragraph 3.1 and make sure you complete the Financial Statement – Harassment, form UH 02.0110. If there is more information you want the court to know about your finances, check the second check box in paragraph 3.1 and write or print the information you want the court to know.

B. If you are seeking protection from someone who has stalked, sexually assaulted or

committed acts of domestic violence against you or the minor(s) listed in your petition,

FORMS NEEDED


4

you may ask the court to waive fees in your case whether or not you have the funds to pay filing fees, court costs or service fees:

Check paragraph 2.2 and then check the sub-box that describes the type of harm you are seeking protection from. Also check the box that applies in paragraph 3.2.

(2) Financial Statement – Harassment - WPF UH-02.0110

If you are asking the court to waive filing fees and surcharges because you cannot afford to pay them, fill in as much information as you can in the Financial Statement. File this form with your motion.

(3) Order Re Wavier of Filing Fees and Surcharges - Harassment - WPF UH-02.0120

Fill out the caption and sign and print your name and the date at the bottom of the form. Bring this order to court with you. The judge or court commissioner will complete the rest of the form.

______________________________________________________________________ Step 3 – Petition for an Order for Protection - Harassment - WPF UH-02.0200 ______________________________________________________________________ Your request for an order for protection starts by filing a petition with the court. Questions to screen for the court’s jurisdiction: Answer the questions in the box at the beginning of the petition. If you answer “yes” to questions 1 and 2, or 3, 4, or 5, you need to file your petition in superior court. If you answer “yes” to 6 and 7, ask for help. You may need to file a petition for a Domestic Violence Order for Protection or for a Sexual Assault Protection Order, instead. Complete the rest of the form: Provide the information requested in paragraphs 1 through 5 of the petition. In paragraph 2, check the box that applies to you. If you are the victim of unlawful harassment and you are the parent of a child under age 18, who is in need of protection, you may check both boxes. The questions in paragraph 3 are to help the court determine whether it has jurisdiction to proceed with your petition. If none of the boxes apply to your situation, leave all of the boxes in paragraph 3 blank. Paragraph 4 asks for information about minors needing protection. The name, age, race, and sex of the child is needed to help the court avoid issuing a protection order that contradicts another protection order. Paragraph 5 asks for other court cases or protection orders involving you and the respondent. This information is also required to help the court avoid issuing a protection order that contradicts another protection order. In the next section, you may ask for the relief you need. If an emergency exists and you might suffer great and irreparable harm if a temporary restraining order is not issued immediately, you may request a temporary order that will last fourteen (14) days. To request a temporary order, check the box next to the protection you are requesting, in the left-hand column. If you request a temporary order, you must tell the court in a statement the reasons why you feel that you might suffer great and irreparable harm if a temporary restraining order is not issued immediately. To


5

request an order for protection, check the box in the second column for the type of protection you are requesting. For both orders you may check more than one box. In the Statement section, you are asked to tell the court why you are requesting an order for protection. Enough information should be provided in the declaration to allow the judge or commissioner to decide whether an order for protection should be issued. You can assist the judge or commissioner in making this determination by listing the approximate dates and places the harassment occurred and by briefly describing how the respondent harassed you. Remember, if you requested a 14-day temporary protection order, you must also tell the court in your statement the reasons why you feel that you might suffer great and irreparable harm if a temporary protection order is not issued immediately. When you finish your statement, complete the certification at the bottom of page 2 of the petition. You must fill in the city and state where you are signing the petition. Below your signature, you need to list an address where the respondent can arrange to have you served with legal documents. You may list an address that is not your residential address where you agree to accept legal documents. ______________________________________________________________________ Step 4 - Confidential Information Form – WPF UH-01.0600, Addendum to Confidential

Information Form – WPF UH-01.0610. ______________________________________________________________________ The Confidential Information Forms gives the court the information it needs to correctly enter your case in the judicial information system. Complete the information requested. If you are listing more than two children in the petition, use an Addendum to Confidential Information form to provide information about additional children. ______________________________________________________________________ Step 5 – Law Enforcement Information Sheet - WPF All Cases-01.0400. ______________________________________________________________________ The Law Enforcement Information Sheet provides law enforcement officials with information that will assist them in serving your papers and enforcing your order. This form is confidential and will not be served on the respondent. This form must be completed in every case. The Law Enforcement Information Sheet provides law enforcement officials with detailed information about the respondent. The Law Enforcement Information Sheet goes out to the law enforcement agency serving the Order of Protection on the respondent. The information contained on the form is for law enforcement and court officials only. Your address and phone number will not be shown or given to the respondent. If you want your address to remain confidential, you may list the name and telephone number and address of someone whom law enforcement can contact to reach you. Provide as much information as possible about the respondent. If you want law enforcement officials to serve your papers you must list the respondent’s current address. Law enforcement personnel cannot enter your order on the statewide law enforcement computer system unless you


6

include at least the year of the respondent’s birth where the respondent’s date of birth is requested. Be sure you complete the hazard information section of the Law Enforcement Information Sheet. This information is for the safety of law enforcement officials while enforcing your order for protection. ______________________________________________________________________ Step 6 – Temporary Protection Order and Notice of Hearing - WPF UH-03.0200. ______________________________________________________________________ This form should be completed if you requested an ex parte temporary Antiharassment protection order in the Petition for an Order for Protection - Harassment (WPF UH-02.0200). If you did not request an ex parte temporary Antiharassment protection order in your petition, skip the remainder of this section and go to Step 7. The table on page one asks for identification information about the minors addressed in the order. You should fill in the next section to the best of your ability. Check the box or boxes that correspond(s) with the temporary restraints you requested in the Petition for an Order for Protection. In the next section, regarding the clerk of court, be careful to make sure the correct law enforcement agency is listed. In the same section, check the appropriate box regarding service of the temporary order upon the respondent. If you want law enforcement officials to serve the respondent with your papers, be careful to make sure the correct law enforcement agency is listed in the blank. If you are unsure which law enforcement agency to fill in, do not fill in the blank. When you present your papers to the judge, tell the judge that you would like a law enforcement agency to serve the respondent and explain why you were unable to fill in the blank. If you need help or have questions about this section, ask the clerk. The next section tells the respondent to appear at the next hearing. You must also appear, or the court will not grant the relief you are requesting. Immediately below the section directing the respondent to appear, is a sentence stating “This Temporary Order for Protection is effective until the next hearing date and time shown below the caption on page one.” Remember to fill in the date, time and place of the next hearing on page 1. The clerk will provide you with the hearing information. Once you have finished filling in the order, sign the Order for Protection in the lower left corner of page 2, on the line for the petitioner. ______________________________________________________________________ Step 7 – Return of Service (Unlawful Harassment) - WPF UH-04.0110. ______________________________________________________________________ This form is to be completed by the person who serves your papers. If at all possible, have law enforcement officials serve your papers on the respondent. You cannot serve your papers yourself.


7

If someone other than a law enforcement official serves your papers, you must make sure the respondent is personally served not less than 5 court days prior to the scheduled hearing. The person serving your papers must be over 18 years of age and a Washington resident. After serving your papers, this person must complete the return of service. You should contact the law enforcement official or other person who is serving your papers several days prior to your hearing to make sure your papers were served. If the respondent is not served at least 5 court days prior to your hearing, the judge or court commissioner cannot issue your Order for Protection unless the respondent appears at the hearing. If the respondent was not properly served, go to your hearing so that a new hearing date can be set. At this time you can request that your temporary protection order be reissued. If you want your temporary protection order reissued, you need to present an Order Reissuing Ex Parte Temporary Protection Order (WPF UH-03.0240) to the court. Once the court signs the Order Reissuing Ex Parte Temporary Protection Order, a copy of the Order Reissuing Ex Parte Temporary Protection Order, the Temporary Protection Order and a Notice of Hearing (WPF UH-3.0200) must be served on the respondent prior to your hearing. Copies of the Order Reissuing Ex Parte Temporary Protection Order and Notice of Hearing forms are available from the clerk. There is no filing fee for the reissuance of a temporary protection order since your case is already open. ______________________________________________________________________ Step 8 – Order for Protection - Harassment - WPF UH-04.0500. ______________________________________________________________________ The Order for Protection is the paper that legally restrains the respondent from further harassing you. In paragraph 2, check the box that applies to the manner in which the respondent was served notice of the hearing. Paragraph 3 asks for identification information about the minors addressed in the order. You should fill in the next section to the best of your ability. Check the box or boxes that correspond(s) with the temporary restraints you requested in the Petition for an Order for Protection. In the next section, regarding the clerk of court, be careful to make sure the correct law enforcement agency is listed. In the same section, check the appropriate box regarding service of the temporary order upon the respondent. If you want law enforcement officials to serve the respondent with your papers, be careful to make sure the correct law enforcement agency is listed in the blank. If you are unsure which law enforcement agency to fill in, do not fill in the blank. When you present your papers to the judge, tell the judge that you would like a law enforcement agency to serve the respondent and explain why you were unable to fill in the blank. If you need help or have questions about this section, ask the clerk. The last paragraph has a blank for the expiration date of the order. You do not need to fill in the blank. If the Order for Protection is granted, the judge will fill in the blank. Once you have finished filling in the order, sign the Order for Protection in the lower left corner of page 2, on the line for the petitioner.


8

______________________________________________________________________ Step 9 – What to Do with the Completed Forms. ______________________________________________________________________ Give your completed forms to the clerk. You should ask for photocopies of all the forms you complete. If someone other than a law enforcement official will be serving your papers you will need to get certified copies of your forms for that person to serve. ______________________________________________________________________ Step 10 – Go to Your Hearing. ______________________________________________________________________ You must appear in court on your scheduled hearing date. If you do not appear at your hearing, an Order for Protection will not be issued. ______________________________________________________________________

General Information ______________________________________________________________________ If you decide that your Order for Protection is no longer necessary or that its conditions should be modified, you may request a hearing to change your order. To modify the conditions of your Order for Protection or to terminate your Order for Protection, complete the Motion to Modify/ Terminate Order for Protection – Harassment form UH 09.0100. To schedule the motion, use form UH 02.0400, Notice of Hearing. Both of these forms are available from the clerk. The clerk will also provide you with hearing information for paragraph 2 of the Notice. You will need to arrange for service of the motion and notice of hearing on the respondent. If someone other than a law enforcement official serves your papers, you must make sure the respondent is personally served not less than 5 court days prior to the scheduled hearing. The person serving your papers must be over 18 years of age and a Washington resident. After serving your papers, this person must complete the return of service. You should contact the law enforcement official or other person who is serving your papers several days prior to your hearing to make sure your papers were served.

Law Enforcement Information Sheet

This document gives information to law enforcement officers so they can locate the respondent and serve the necessary forms on the respondent. It also allows law enforcement to enter an order into a state-wide database. Try to give as much information as you can.

This FORM will not be shown to the Respondent. It will not be served on to the Respondent.

Print Clearly!! Restrained Person’s Information The restrained person is the respondent. Fill in each of the boxes about the respondent as best you can. The more information you can give, the easier it is for law enforcement officers to locate the respondent and serve the papers. Protected Person’s Information The protected person is the petitioner. Fill in each of the boxes asking for information about the protected person. If you are filing on behalf of the petitioner, write your name and contact phone number in the space provided. This allows law enforcement officers to notify you if they cannot find the respondent and need more information from you. Hazard Information If the respondent has weapons, guns/rifles, knives, explosives, check the boxes that apply. Fill in the “Other” box if the respondent has a different kind of weapon than what is listed on the form. In “Location of Weapons,” check the box that applies to where the respondent has the weapon(s). Check the boxes regarding the respondent’s history. You may check more than one box. For example, if the respondent has experienced alcohol or drug abuse and mental health problems, check both of those boxes.

Mason County Sheriff’s Office Confidential Request for Subject History Information

Mason County District Court works with the Mason County Sheriff’s Office to get additional information that the petitioner may not have (i.e. driver’s license number, date of birth, correct address, etc.). Please complete the form the best you can. Requestor Information: This is the petitioner’s information. Subject Information: This is the respondent’s information.

WPF All Cases 01.0400 LEIS (6/2020)

LAW ENFORCEMENT INFORMATION

Do NOT serve or show this sheet to the restrained person! Do NOT FILE in the court file. Give this form to law enforcement.

Type or print clearly! This completed form is required by law enforcement. This information is necessary to serve, enforce, and enter your order

into the statewide law enforcement computer. Fill in the following information as completely as possible. Court: Case Number:

[ ] Domestic Violence [ ] Dissolution/Separation/Invalidity/Non-parental Custody/Paternity [ ] Unlawful Harassment [ ] Vulnerable Adult [ ] Sexual Assault [ ] Stalking

Restrained Person’s Information (This is the person that you want the court to restrain.)

Name: First Middle Last Nickname Relationship to Protected Person

Date of Birth Sex Race Height Weight Eye Color

Hair Color Skin Tone Build

Last Known Address Street: City: State: Zip:

Phone(s) w/Area Code

Need Interpreter? Yes or No Language:

Email address:

Employer

Employer's Address WORK Hours: Phone: ( )

Vehicle License Number

Vehicle Make and Model Vehicle Color Vehicle Year Drivers License or ID number State

Does the restrained person have a disability, brain injury, or impairment requiring special assistance when law enforcement serves the order? [ ] No [ ] Yes. If yes, describe (continue on back, if needed): Hazard Information Restrained Person’s History Includes: [ ] Involuntary/Voluntary Commitment [ ] Suicide Attempt or Threats [ ] Assault [ ] Assault with Weapons [ ] Alcohol/Drug Abuse [ ] Other: Weapons: [ ] Handguns [ ] Rifles [ ] Knives [ ] Explosives [ ] Other: Location of Weapons: [ ] Vehicle [ ] On Person [ ] Residence Describe in detail: Current Status (Circle Yes, No or N/A.) Is the restrained person a current or former cohabitant as an intimate partner? Y N

Are you and the restrained person living together now? Y N

Does the restrained person know he/she may be moved out of the home? Y N N/A

Does the restrained person know you’re trying to get this order? Y N

Is the restrained person likely to react violently when served? Y N

WPF All Cases 01.0400 LEIS (6/2020)

Protected Person’s Information (This is the person you want the court to protect.)

Name: First Middle Last Drivers License or ID number Date of Birth Sex Race Height Weight Eye Color Hair Color Skin Tone Build

If your information is not confidential, you must enter your address and phone number(s) below.

Current Address Street: City: State: Zip:

Phone(s) w/Area Code

Need interpreter? Yes or No Language:

Email address:

If your information is confidential, you must provide the name, address, and phone number of someone willing to be your “contact.”

Contact Name Contact Address

Contact Phone

If you filed for someone else, list your name, phone number, and address:

Minor’s Information

Name: First Middle Last Sex Race Birth date Resides With

Below, describe the minor’s relationship to the protected or restrained person using terms such as: child, grandchild, stepchild, nephew, none.

Name: First Middle Last Minor’s Relationship to Protected Person

Minor’s Relationship to Restrained Person

Victim’s Household Members or Adult Children Protected

Name: birth date:

Name: birth date:

Name: birth date:

Name: birth date:

Mt and Decl for Civil Fee Waiver - Harassment (MTWVF) - Page 1 of 2 UH 02.0100 (07/2019) – GR 34, RCW 10.14.055, .060

The document to which this certificate is attached is a full, true and correct copy of the original on file and of record in my office. IN WITNESS WHEREOF, I have hereunto set my hand and affixed the seal of said Court this ______ day of ___________, ______ _____________________________________ Clerk of the District Court of the State of Washington In and for the County of Mason

District Court of Washington For Mason County

Petitioner, vs.

Respondent.

No. ________________________ Motion and Declaration For Waiver of Filing Fees and Surcharges - Harassment (MTWVF) (RCW 10.14.060; RCW 10.14.055)

I. Motion

1.1 I am the petitioner in this action.

1.2 I am asking for a waiver of all filing fees and surcharges.

II. Basis for Motion

2.1 [ ] GR 34 allows the court to waive “filing fees or surcharges the payment of which is a condition precedent to a litigant's ability to secure access to judicial relief” for a person who is indigent. RCW 10.14.060 provides that if the petitioner’s request for fee waiver is granted, “then no fees for service may be charged to the petitioner.” As outlined below, I am indigent.

2.2 [ ] RCW 10.14.055 allows the court to waive “filing fees or surcharges the payment of which is a condition precedent to a litigant's ability to secure access to judicial relief” for a person who is seeking relief from a person:

[ ] who has stalked them as that term is defined in RCW 9A.46.110; or [ ] who has engaged in conduct that would constitute a sex offense as defined in

RCW 9A.44.130; or [ ] from a person who is a family or household member as defined in

RCW 26.50.010 who has engaged in conduct that would constitute domestic violence as defined in RCW 26.50.010.

Mt and Decl for Civil Fee Waiver - Harassment (MTWVF) - Page 2 of 2 UH 02.0100 (07/2019) – GR 34, RCW 10.14.055, .060

RCW 10.14.060 provides that if the petitioner’s request for fee waiver is granted, “then no fees for service may be charged to the petitioner.”

Dated: Signature of Requesting Party Print or Type Name

III. Declaration I declare that,

3.1 [ ] I cannot afford to meet my necessary household living expenses and pay the filing fees and surcharges imposed by the court. Please see the attached Financial Statement, which I incorporate as part of this declaration.

[ ] In addition to the information in the financial statement I would like the court to consider the following:

.

3.2 [ ] I am seeking protection from the respondent who: [ ] has stalked me, or the minor child(ren) listed in the petition; [ ] has engaged in conduct that would constitute a sex offense as defined in

RCW 9A.44.130; or [ ] is a family or household member as defined in RCW 26.50.010 who has

engaged in conduct that would constitute domestic violence as defined in RCW 26.50.010;

as described in the Statement in the Petition for Order for Protection – Harassment.

[ ] (Check if applies.) I filed this motion by mail. I enclosed a self-addressed stamped envelope with the motion so that I can receive a copy of the order once it is signed.

I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at (city) ______________________, (state) ________ on (date) __________________. Signature Print or Type Name

Financial Statement - Harassment (Attachment) - Page 1 of 1 UH 2.0110 (07/2011) GR 34, RCW 10.14.060

Case Name:_____________________________ Case Number:__________________

Financial Statement - Harassment (Attachment) 1. My name is: 2. [ ] I provide support to people who live with me: How many? Age(s):

3. My Monthly Income: 6. My Monthly Household Expenses:

Employed [ ] Unemployed [ ] Rent/Mortgage: $ Employer’s Name: Food/Household Supplies: $ Gross pay per month (salary or hourly pay):

$ Utilities: $

Take home pay per month: $ Transportation: $

4. Other Sources of Income Per Month in my Household:

Ordered Maintenance actually paid:

$

Source: $ Ordered Child Support actually paid:

$

Source: $ Clothing: $

Source: $ Child Care: $

Source: $ Education Expenses: $

Sub-Total: $ Insurance (car, health): $

[ ] I receive food stamps. Medical Expenses: $

Total Income, lines 3 (take home pay) and 4: $ Sub-Total: $

5. My Household Assets: 7. My Other Monthly Household Expenses:

Cash on hand: $ $ Checking Account Balance: $ $ Savings Account Balance: $ $ Auto #1 (Value less loan): $ $ Auto #2 (Value less loan): $ Sub-Total: $

Home (Value less mortgage): $ 8. My Other Debts with Monthly Payments:

Other: $ $ /mo Other: $ $ /mo Other: $ $ /mo Other: $ $ /mo Other: $ Sub-Total: $

Total Household Assets: $ Total Household Expenses and Debts, lines 6, 7, and 8: $

Date: Signature:

Order re Civil Fee Waiver _Harassment (ORPRFP, ORDYMT) - Page 1 of 2 UH 02.0120 (07/2011) – GR 34, RCW 10.14.055, .060


Petitioner, vs. Respondent.

No. ____________________________ Order Re Waiver of Filing Fees and Surcharges - Harassment [ ] Granted (ORPRFP) [ ] Denied (ORDYMT)

[X] Clerk’s Action Required 3.1

I. Basis

The court received the motion to waive filing fees and surcharges filed by or on behalf of the petitioner.

II. Findings The Court reviewed the motion and supporting declaration(s). Based on the declaration(s) and any relevant records and files, the Court finds: 2.1 [ ] The petitioner is indigent based on the following: He or she:

[ ] is represented by a qualified legal aid provider that screened and found the applicant eligible for free civil legal aid services; and/or

[ ] receives benefits from one or more needs-based, means-tested

assistance programs; and/or

[ ] has household income at or below 125% of the federal poverty guideline; and/or

[ ] has household income above 125% of the federal poverty guideline but

cannot meet basic household living expenses and pay the fees and/or surcharges; and/or

[ ] other:

.

Order re Civil Fee Waiver _Harassment (ORPRFP, ORDYMT) - Page 2 of 2 UH 02.0120 (07/2011) – GR 34, RCW 10.14.055, .060

2.2 [ ] The petitioner is seeking protection from a person who:

[ ] has stalked them as that term is defined in RCW 9A.46.110;

[ ] engaged in conduct that would constitute a sex offense as defined in RCW 9A.44.130; or

[ ] is a family or household member as defined in RCW 26.50.010(2) who has

engaged in conduct that would constitute domestic violence as defined in RCW 26.50.010(1).

2.3 [ ] Other: .

III. Order Based on the findings the court orders: 3.1 [ ] The motion is granted, and

[ ] all filing fees and surcharges the payment of which is a condition

precedent to the petitioner’s ability to secure access to judicial relief are waived.

[ ] Law Enforcement shall serve all papers in this action without charging a

fee for service to the petitioner. [ ] other:

. 3.2 [ ] The motion is denied. 3.3 If there is a material change in financial circumstances, the ruling can be revisited by the

court or the petitioner.

If the motion was granted and the court, upon review, later finds that either the petitioner or another responsible party to this proceeding has sufficient resources to pay the waived filing fees or surcharges, the Court may modify this order and require the petitioner or another party to pay the filing fees and/or surcharges that have been waived by this order.

Dated: Judge/Commissioner Presented by: Signature of Petitioner or Lawyer/WSBA No. Print or Type Name Date

Motion for Surrender and Prohibition of Weapons (Civil) (MT) - Page 1 of 3 WPF All Cases 02-010 Mandatory (06/2020) - RCW 9.41.800

The document to which this certificate is attached is a full, true and correct copy of the original on file and of record in my office. IN WITNESS WHEREOF, I have hereunto set my hand and affixed the seal of said Court this ______ day of ___________, ______ _____________________________________ Clerk of the District Court of the State of Washington In and for the County of Mason


No.

_____________________________ _________ Petitioner DOB vs. _____________________________ _________ Respondent DOB

Motion for Surrender and Prohibition of Weapons (MT)

Use this motion to ask the court for a weapons order when:

• you did not ask the court for a weapons order as a part of your protection order or restraining order, • the final protection order or restraining order issued by the court did not include a weapons order.

1. I am protected by a civil protection order issued on _________________ (date) in this

case: [ ] Domestic Violence, RCW 26.50 [ ] Anti-harassment, RCW 10.14 [ ] Sexual Assault, RCW 7.90 [ ] Stalking, RCW 7.92 [ ] Restraining Order, RCW 26.09, 26.10, 26.26A, 26.26B

2. [ ] The court must issue an Order to Surrender and Prohibit Weapons because the order of

protection included provisions that the respondent: • is restrained from causing physical harm, bodily injury, assault, including sexual

assault, and from molesting, harassing, threatening, or stalking, the protected person/s;

• had actual notice of the hearing and an opportunity to be heard; and • represented a credible threat to the physical safety of the protected person/s; and • the respondent and the protected person are intimate partners because they are:

[ ] current or former spouses or domestic partners. [ ] parents of a child-in-common. [ ] age 16 or older and are/were in a dating relationship, and are currently

residing together or resided together in the past. [ ] age 16 or older and are/were in a dating relationship, but have never resided

together. Or


3. [ ] The restrained person (name) __________________________: (check all that apply)

[ ] has used, displayed, or threatened to use a firearm or other dangerous weapon in a felony. Describe this offense:

.

[ ] is ineligible to possess a firearm under the provisions of RCW 9.41.040. Describe this offense:

.

[ ] has possession of a firearm or other dangerous weapon which presents a serious and imminent threat to public health or safety, or to the health or safety of any individual. My concern for imminent threat is based on the following:

.

4. Information about the firearms or other dangerous weapon/s:

What kind of firearm or other dangerous weapon?

Where is it located?


5. The restrained person and I are:

[ ] Intimate Partners because we are (check all that apply):

[ ] current or former spouses or domestic partners, [ ] parents of a child-in-common, [ ] age 16 or older and are/were in a dating relationship, and are currently residing together or resided together in the past, [ ] age 16 or older and are/were in a dating relationship, but have never resided together.

[ ] Family or household members because we are (check all that apply):

[ ] current or former adult cohabitants as roommates, [ ] adult in-laws, [ ] adults related by blood, [ ] parent and child, [ ] stepparent and stepchild, [ ] grandparent and grandchild.

6. I request that the court:

• Prohibit the restrained person from accessing, obtaining, or possessing any firearms or other dangerous weapons.

• Prohibit the restrained person from obtaining or possessing a concealed pistol license.

• Require the restrained person to immediately surrender all firearms, other dangerous weapons, and any concealed pistol licenses issued under RCW 9.41.070.

• [ ] Order temporary surrender of all firearms, other dangerous weapons, and any concealed pistol licenses issued under RCW 9.41.070 without notice to the restrained person because [ ] irreparable injury could result if an order is not issued until the time for response has elapsed; [ ] respondent’s possession of a firearm or other dangerous weapon presents a serious and imminent threat to public health or safety or the health or safety of any individual.

I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed on: (date) at (place) , Washington. Signature of Protected Person/Attorney WSBA No. Print Name Protected person or attorney, you must:

• Schedule a hearing on the Motion for Order to Surrender and Prohibit Weapons. • Arrange to serve notice of the hearing on the other party. • File proof of service in the court file prior to the hearing.

Or Surrender and Prohibit Weapon Issued Without Notice (Civil) ((ORWPN) - Page 1 of 3 WPF All Cases 02-030 Mandatory (06/2020) – RCW 9.41.800

The document to which this certificate is attached is a full, true and correct copy of the original on file and of record in my office. IN WITNESS WHEREOF, I have hereunto set my hand and affixed the seal of said Court this ______ day of ___________, ______ _____________________________________ Clerk of the District Court of the State of Washington In and for the County of Mason District Court of Washington For Mason County

Petitioner vs. Respondent

No. Order to Surrender Weapons Issued without Notice [ ] and Prohibit Weapons (ORWPN) (Clerk's Action Required) Next Hearing Date/Time: At: 419 N 4th Street, Shelton WA 98584

This order is based on the findings in the order issued on ______________________ (date). Restrained person (name) ______________________________: You must immediately surrender all firearms and other dangerous weapons in your possession or control, and any concealed pistol licenses issued under RCW 9.41.070 to the local law enforcement agency: ___________________________________ (fill in if known).

You must immediately surrender all firearms and other dangerous weapons subject to this order, including but not limited to the following:

Attach sheet if there are more to list. [ ] You are prohibited from accessing, obtaining, or possessing any firearms or other dangerous

weapons, or obtaining or possessing a concealed pistol license. This order expires At the same time as the protection order entered under this case

number. If you have firearms, other dangerous weapons, or concealed pistol licenses:


Step 1: When served, immediately surrender all firearms, other dangerous weapons, and concealed pistol licenses to the law enforcement officer who serves you.

or Step 1: If you were present at the hearing at which the order was entered, immediately

surrender all firearms, other dangerous weapons, and concealed pistol licenses to the local law enforcement agency on the same day as the hearing. Contact the local law enforcement agency for directions on how to immediately surrender the firearms, dangerous weapons and concealed pistol licenses.

For all cases: Step 2: Get a receipt for the firearms, other dangerous weapons, and concealed pistol

licenses from law enforcement. Step 3: Complete the Proof of Surrender form and file it with the receipt. Step 4: File the documents with the clerk of the court within 5 judicial (court) days.

If you do not have firearms, other dangerous weapons, or concealed pistol licenses:

Step 1: Immediately complete and sign the Declaration of Non-Surrender form. Step 2: File the declaration with the clerk of the court within 5 judicial (court) days.

The Law Enforcement Officer serving this order shall inform you that the order is in effect upon service and that you must immediately surrender all firearms, other dangerous weapons and any concealed pistol licenses issued under RCW 9.41.070. The serving officer shall conduct any search for firearms, other dangerous weapons, and concealed pistol licenses as permitted by law. The serving officer shall take possession of:

• All firearms, • Other dangerous weapons, • Concealed pistol licenses belonging to respondent,

that are surrendered, in plain sight, or discovered during a lawful search. RCW 9.41.801.

Washington Crime Information Center (WACIC) Data Entry

The clerk of the court shall forward a copy of this order, with the temporary protection order, on or before the next judicial day to the: _____________________________ [ ] County Sheriff's Office or [ ] City/Town Police Department where the protected person lives which shall enter this order into WACIC.

Service

[ ] The clerk will electronically forward this order to ________________________, [ ] county or [ ] city/town law enforcement where the respondent lives for service of respondent.

[ ] The restrained person appeared and was informed of the order by the court; further service is not required.


Warning! • If you fail to comply with this order, you may be found in contempt of court and/or be

charged with a misdemeanor and punished accordingly.

• You may also be charged with a crime up to and including a felony if you are found to own, possess, or control a firearm or other dangerous weapon.

Dated _______________ at _________ a.m./p.m. _________________________________ Judge/Commissioner I acknowledge receipt of a copy of this order.

Signature of Restrained Person Print Name

Signature of Restrained Person’s Attorney WSBA No. Print Name

Signature of Protected Person or Attorney WSBA No. Print Name You may download the forms listed in this order from the Washington Courts’ forms website: http://www.courts.wa.gov/forms/.

http://www.courts.wa.gov/forms/

Pt for an Or for Protection – Harassment/Stalking (PTORAH, PTORSTK) – Page 1 of 7 WPF UHST-02.0200 Mandatory (06/2020) – RCW 10.14.040, .800, RCW 7.92.030

The document to which this certificate is attached is a full, true and correct copy of the original on file and of record in my office. IN WITNESS WHEREOF, I have hereunto set my hand and affixed the seal of said Court this ______ day of ___________, ______ _____________________________________ Clerk of the District Court of the State of Washington In and for the County of Mason District Court of Washington For Mason County

Petitioner, vs. Respondent.

No. Petition for an Order for Protection - [ ] Harassment (PTORAH) and/or [ ] Stalking (PTORSTK)

This is a Petition for an Order for Protection against Harassment

and/or Stalking as checked in the caption. I believe:

[ ] I am a victim of stalking. [ ] _________________________ (name) is the victim of stalking and he/she is a minor or vulnerable adult. The respondent has been

• stalking the victim either in person or cyber stalking, and • repeatedly contacting the victim or attempting to contact or monitor the victim for no

lawful purpose and his/her actions caused the victim to feel intimidated, frightened, or threatened.

[ ] I am a victim of unlawful harassment. [ ] _____________________________ (name) is a victim of unlawful harassment and

he/she is a minor. The respondent’s actions toward the victim have seriously alarmed, annoyed, or harassed the victim, or are detrimental to the victim and serve no legitimate or lawful purpose. The respondent’s actions have caused substantial emotional distress to the victim or caused me to fear for the well-being of my child.

How do the victim and respondent know each other? _________________________

I have given a detailed explanation below.


1. Who is the petitioner?

My name is (please print) _________________________________. I am the petitioner. [ ] I am 18 or older and I am petitioning on my own behalf. [ ] I am 16 or 17 and I am petitioning on my own behalf. [ ] I am the parent or guardian of child/ren under age 18 and I am petitioning on their

behalf: Children’s Name/s

(First, Middle Initial, Last)

Age

[ ] I am not the parent or guardian, but the child/ren live/s with me and I am petitioning on their behalf and the respondent is not a parent.

Children’s Name/s (First, Middle Initial, Last) Age

[ ] I am filing this petition on behalf of petitioner, (name) ________________________, a vulnerable adult as defined in RCW 74.34.020, who is a victim of stalking. I am an interested person as defined in RCW 74.34.020(10). My relationship to this petitioner is _____________________.

2. Is the respondent 18 years of age or older?

[ ] Yes [ ] No (If no, use the Petition for Order for Protection Harassment/Stalking Respondent Under Age 18, instead of this petition.)

3. Where do the parties live?

Petitioner lives in ____________________________________ County. Did the petitioner leave their residence because of stalking conduct and that is the county of their new residence?

[ ] Yes [ ] No Children named above live in County. Respondent lives in ___________________________________ County.

4. Where did the Conduct take place?

The conduct took place in County.


Statement describing the victim/s need for protection from the respondent • Write clearly. If you need more space below, attach additional page/s. Do not write on

the back. 5. Describe what the Respondent did or said that you think is harassment or stalking.

• You must describe what the respondent actually said. • You must describe what the respondent actually did.

The respondent has committed acts of harassment or stalking as follows: A. Describe the most recent incident of harassment or stalking. Date and time (on or around): __________________________________________________ Location: __________________________________________________________________ What did the respondent do or say that you believe to be harassing or stalking behavior? .


How did the respondent make these statements? [ ] in person [ ] mail/written notes [ ] e-mail [ ] text [ ] phone [ ] social media (such as Facebook and Twitter) [ ] other (describe): _________________________________________________________. B. Describe other incidents of harassment or stalking. For each incident, include the date,

time (on or about), location, what was said, how statements were made, and what was done to a victim.

. 6. How did the incidents you describe above make you, the minor, or the vulnerable adult feel? .


7. Has the respondent used, displayed, or threatened to use a firearm or other dangerous

weapon in a felony? Please describe: . 8. Is the respondent ineligible to possess a firearm under the provisions of RCW 9.41.040?

Please describe: . 9. Does possession of a firearm or other dangerous weapon by the respondent present a

serious and imminent threat to public health or safety, or to the health or safety of a victim? Please describe:

. 10. Do you have any evidence of the harassment or stalking conduct other than testimony?

[ ] No [ ] Yes. I have attached the following evidence:

[ ] Copy of mail or written notes [ ] Copy of text messages [ ] Copy of email messages [ ] Copy of social media messages [ ] Police report [ ] Declaration or Affidavit from the following witness: ___________________ [ ] Other (describe): _____________________________________________

11. Has/have the victim/s or the respondent ever requested or obtained protection from the

other person in a restraining order, civil protection order, or criminal no-contact order? If yes, list the type of order, the name of the court, the approximate date of the order, and whether the request was granted:


12. Is there any other litigation between the victim/s and the respondent? This includes all matters - pending or past - such as parenting plans, landlord-tenant disputes, employment disputes, or property disputes. If yes, provide case number/s if known, type of case, and name of court: .

Requests 13. I ask the Court for an order approving the following requests for protection: I Request an Order for Protection following a hearing that will:

[ ] No Contact: Restrain the respondent from making any attempts or having any contact,

including nonphysical contact, with the person/s to be protected, directly, indirectly, or through third parties, regardless of whether those third parties know of the order, except for mailing of court documents.

[ ] Surveillance: Prohibit or restrain the respondent from making any attempt to keep or from keeping the person/s to be protected under surveillance, including electronic surveillance.

[ ] Exclude from places: Exclude the respondent from the [ ] residence [ ] workplace [ ] school [ ] day care of the person/s to be protected.

[ ] Stay Away: Prohibit or restrain the respondent from entering or being within, or from knowingly coming within, or knowingly remaining within ________ (distance) of the [ ] residence [ ] workplace [ ] school [ ] day care of the person/s to be protected. [ ] other locations: _______________________________________________.

[ ] Other:

[ ] Evaluation: Order the respondent to have a [ ] mental health [ ] chemical dependency evaluation. [ ] other: ______________________________________________________________.

[ ] Pay Fees and Costs: Require the respondent to pay fees and costs of this action, which may include administrative court costs and service fees and petitioner’s costs including attorneys’ fees.

[ ] Surrender Firearms: Require the respondent to immediately surrender all firearms, other dangerous weapons, and any concealed pistol licenses, and prohibit the respondent from accessing, obtaining or possessing firearms, or other dangerous weapons, or concealed pistol licenses.

[ ] Duration: Remain effective longer than one year because respondent is likely to resume acts of unlawful harassment or stalking conduct against the persons to be protected if the order expires in a year.


Emergency temporary protection (up to 14 days) until the court hearing: [ ] An emergency exists as described below. I request that a Temporary Protection Order

granting the relief I requested above for a no-contact, surveillance, exclude from places, or stay away order be issued immediately, without prior notice to the respondent, be effective until the hearing.

[ ] I also request a temporary surrender and prohibition of all firearms, other dangerous weapons, and concealed pistol licenses without notice to the other party because irreparable injury could result if an order is not issued until the hearing.

What irreparable harm would result if an order is not issued immediately without prior notice to the respondent? __________________________________________________________________________ __________________________________________________________________________ _________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.

Dated: at Washington.

Petitioner

Print or type name

I agree to receive legal documents at this address: _______________________________________________________________________. [ ] This address is not my home address because my family, household, or I would be at risk of abuse by respondent if I disclosed my home address.

Worksheet for the Harassment and/or Stalking Petition · 2020. 7. 28. · you complete the...

Documents

Transcript of Worksheet for the Harassment and/or Stalking Petition · 2020. 7. 28. · you complete the...