Form 2	Application for a Personal Protection Order
Domestic Violence and Protection Orders Act 2008, s 18
In the Magistrates Court of the Australian Capital Territory
RO ………./………………

APPLICANT			.........................................................................

RESPONDENT		...................................................................

Respondent’s address:	.........................................................................

				.........................................................................

I, …………………………………………………………………………………………… (name of applicant) being an aggrieved person/police officer/parent or guardian of the aggrieved person (delete as applicable) apply for a Personal Protection Order against the respondent for a period of ………… (no more than 12) months and seek the conditions set out below.  
I seek that any order made include the following child/children: (include full names and date/s of birth):

Grounds - The respondent has:
(a) engaged in personal violence offence toward me/toward …………………………………. (insert name of person)*, 
(b) threatened personal violence offence toward me/toward ……………………………………(insert name of person)*
* (delete as applicable)
Please provide details of conduct constituting (a) or (b) including date/s on which the conduct has occurred.  If there is insufficient space, please attach an extra sheet setting out the details.	

	

	

	
	
Unless the respondent is restrained, I believe that the respondent is likely to engage in similar conduct in the future.  
An interim order IS SOUGHT in this matter □	An interim order is NOT SOUGHT in this matter □
Is the respondent under 18 years of age? □ Yes (age/date of birth ………………………….)     □ No
Does the respondent have a disability and/or mental illness?  □ Yes (provide details)   □ No 

 A person’s conduct constitutes personal violence if the conduct caused personal injury to the aggrieved person or damage to the aggrieved person’s property or is harassing or offensive to the aggrieved person

The following court/tribunal proceedings are pending/finalised between the parties 
If there is insufficient spaces please attach an extra sheet with the additional matters.
Type of proceeding 	Court/Tribunal	Next court date	Other parties (if applicable)	

Is this a school dispute?  □ Yes (if yes, provide school’s details)			□ No

NOTICE TO APPLICANT: A copy of this form is provided to the respondent.  If you do not want your home or work address disclosed to the respondent, do not include them on this form
I seek the respondent be:
□	a)	prohibited from being on premises where the aggrieved person lives (list address);
……………………………………………………………………………………………………………………	
□	b)	prohibited from being on premises where the aggrieved person works (list address);
…………………………………………………………………………………………………………………….	
□	c)	prohibited from being on premises where the aggrieved person is likely to be (list address);
…………………………………………………………………………………………………………………….	
□	d)	prohibited from being in a particular place (name place);
…………………………………………………………………………………………………………………….	
□	e)	prohibited from being within ………….metres of the aggrieved person;
	□EXCEPT at Court		□EXCEPT at counselling/mediation
	□Other (specify)…………………………………………………………………………………….....................	
□	f)	prohibited from contacting the aggrieved person, 
	□EXCEPT at Court 			□EXCEPT at counselling/mediation
	□EXCEPT in writing			□EXCEPT through a solicitor
	□EXCEPT in order to facilitate Court proceedings
	□Other (specify)………………………………………………………………………………………………….	
□	g)	prohibited from harassing, threatening or intimidating the aggrieved person;	
□	h)	prohibited from damaging the aggrieved person’s property;	
□	i)	prohibited from causing someone else to do something mentioned in paragraph (f), (g) or (h);	
□	j)	prohibited from taking possession of particular personal property that is reasonably needed 
by the aggrieved person or a child/children of the aggrieved person (provide description of the property);
…………………………………………………………………………………………………………………….	
□	k)	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/children of the aggrieved person 
(provide description of the property);
………………………………………………………………………………………………………………………………	
□	l)	prohibited from doing anything mentioned in paragraphs (a) to (g) or (i) in relation to a child/children of
the aggrieved person.	
Dated this …………. day of  ………………...….. 20       ………………………………………………………….	
Signature of applicant/representative