Form 1	Domestic Violence and Protection Orders Act 2001
(see s 11 (1))
Application for domestic violence order

Australian Capital Territory

I (name of applicant)
being an aggrieved person/representative of an aggrieved person/police officer, apply for orders as set out in this application.

I believe the Respondent has: (State briefly and concisely the facts relied upon)
(a)	Engaged in Conduct that constitutes a Domestic Violence Offence in that: 
(b)	Threatened to engage in conduct that would constitute a Domestic Violence Offence in that:
(c)	Engaged in conduct of an offensive or harassing nature in that:
and unless the Respondent is restrained I believed that such conduct is likely to happen again.

The Applicant seeks orders for a period of 	(specify period not exceeding 24 months)	in the terms outlined in this form.

An interim order is sought in this matter (or) is not sought at present.

The orders sought by the applicant are that the respondent be: 
(a)	prohibited from being on premises where the aggrieved person lives;
(b)	prohibited from being on premises where the aggrieved person works;
(c)	prohibited from being on premises where the aggrieved person is likely to be; 
(d)	prohibited from being in a particular place (name place);
(e)	prohibited from being within a particular distance from the aggrieved person;
(f)	prohibited from contacting, harassing, threatening or intimidating the aggrieved person;
(g)	prohibited from damaging the aggrieved person’s property;
(h)	prohibited from causing someone else to do something mentioned in paragraph (f) or (g);
(i)	prohibited from taking possession of particular personal property that is reasonably needed by the aggrieved person or a child of the aggrieved person;
(j)	required to give the aggrieved person personal property that is in the respondent’s possession and is reasonably needed by the aggrieved person or a child of the aggrieved person.
(k)	prohibited from doing anything mentioned in paragraphs (a) to (g) or (i) in relation to a child of the aggrieved person;

Dated this 	day of 		20	[Signature]
Applicant/Representative

Endnotes
This republication includes amendments made under the Legislation Act, part 11.3 (Editorial changes).

©  Australian Capital Territory 2006