BEFORE

completing and submitting this Protective Order Intake Form please contact the Nueces County Attorney’s office at (361) 888-0391 for further guidance.

A Protective Order Application should be submitted only after you have contacted the office and receive a date and time for a telephonic interview.

Please check that you agree before continuing.

By continuing I agree that I am willing to complete a digital version of the document(s) and that information about my user session will be stored.

Protective Order Application

Form Page 1

I. Applicant's Information

I. Applicant's Name

I. Applicant's Home Address

I. Applicant's City

I. Applicant's Zip Code

I. Applicant's Home Phone Number

I. Applicant's Cell Phone Number

I. Applicant's Sex

I. Applicant's Date of Birth

I. Applicant's Age

I. Applicant's Race

I. Applicant's Social Security Number

I. Applicant's Drivers License or ID Number

I. Applicant's Email Address

I. Applicant's Place of Employment

I. Applicant's Work City

I. Applicant's Work Zip Code

I. Applicant's Work Address

I. Applicant's Work Phone Number

I. Can Applicant be called at work?

Yes

I. Contact name and phone number of someone who can reach Applicant

I. Do you currently live with Respondent?

Yes

I. If no, do you want this information to be kept CONFIDENTIAL from Respondent?

Yes

II. Respondent's Information

II. Respondent's Name

II. Respondent's Home Address

II. Respondent's City

II. Respondent's Zip Code

II. Respondent's Date of Birth

II. Respondent's Place of Birth

II. Respondent's Age

II. Respondent's Sex

II. Respondent's Race

II. Respondent's Height

II. Respondent's Weight

II. Respondent's Eyes

II. Respondent's Hair

II. Respondent's Social Security

II. Respondent's Drivers License or ID Number

II. Respondent's Phone Number

II. Respondent's Place of Employment

II. Respondent's City

II. Respondent's Zip Code

II. Respondent's Work Address

II. Respondent's Work Phone Number

II. Respondent's Work Hours

II. Respondent's Name of Supervisor

II. Is the Respondent on Probation or Parole?

Yes

II. If yes, name of Probation or Parole Officer

II. For which offense is the Respondent on Probation or Parole?

II. Other known arrests or convictions

II. Outstanding warrants?

Yes

II. If yes, for what offense?

II. Respondent s Vehicle License Plate Number

II. Respondent's State vehicle is registered

II. Respondent's Vehicle Year

II. Respondent's Vehicle Make

II. Respondent's Vehicle Model

II. Respondent's Vehicle Color

II. Please list physical characteristics of Respondent such as tattoos, scars or other features

Form Page 2

Statement in Support of Protective Order

MY NAME IS

On (date of recent incident)

at approximately (time)

a.m. or p.m. (time)

p.m.

a.m.

at (location)

(county)

(name of Respondent)

(relationship)

assaulted or threatened me by:

Form Page 3

III. Information Regarding Children of THIS MARRIAGE or RELATIONSHIP

III. Child 1 Name

III. Child 1 Social Security Number

III. Child 1 Date of Birth

III. Child 1 Name and Address of School or Child Care

III. Child 2 Name

III. Child 2 Social Security Number

III. Child 2 Date of Birth

III. Child 2 Name and Address of School or Child Care

III. Child 3 Name

III. Child 3 Social Security Number

III. Child 3 Date of Birth

III. Child 3 Name and Address of School or Child Care

III. Child 4 Name

III. Child 4 Social Security Number

III. Child 4 Date of Birth

III. Child 4 Name and Address of School or Child Care

III. Child 5 Name

III. Child 5 Social Security Number

III. Child 5 Date of Birth

III. Child 5 Name and Address of School or Child Care

III. Child 6 Name

III. Child 6 Social Security Number

III. Child 6 Date of Birth

III. Child 6 Name and Address of School or Child Care

III. Do these children live with you?

Yes

III. If not, with whom do they live?

IV. Information Regarding Children of OTHER MARRIAGES OR RELATIONSHIP(S)

IV. Child 1 Name

IV. Child 1 Social Security Number

IV. Child 1 Date of Birth

IV. Child 1 Name and Address of School or Child Care

IV. Child 2 Name

IV. Child 2 Social Security Number

IV. Child 2 Date of Birth

IV. Child 2 Name and Address of School or Child Care

IV. Child 3 Name

IV. Child 3 Social Security Number

IV. Child 3 Date of Birth

IV. Child 3 Name and Address of School or Child Care

IV. Child 4 Name

IV. Child 4 Social Security Number

IV. Child 4 Date of Birth

IV. Child 4 Name and Address of School or Child Care

IV. Do these children live with you?

Yes

IV. If not, with whom do they live?

Form Page 4

V. Court Orders or Proceedings Regarding Children

V. Is there any ongoing or pending COURT ORDER or COURT PROCEEDINGS regarding your children?

Yes

V. What is the Cause Number?

V. Who IS or WAS your Attorney?

V. Did Child Protective Service (CPS) give you a Safety Plan for the children?

Yes

V. Did Child Protective Services (CPS) have an OPEN investigation for the children?

Yes

VI. What is the Relationship between you and the Respondent?

Check all that apply and provide additional information as needed.

VI. Married

Married

VI. Married: When

VI. Date of Separation

VI. Divorced

Divorced

VI. Divorced: When

VI. Common-Law Married

Common-Law Married

VI. Common-Law Married: When

VI. Common-Law Married: Date of Separation

VI. Biological Parent of same child

Biological Parent of same child

VI. Dating: How long did you date

VI. Dating: Date of Separation

VI. Living Together: How long and when did you live together

VI. Living Together: Date of Separation

VI. Family Member

Family Member

VI. Family Member: Relationship

VI. Victim of sexual assault committed by the Respondent

Victim of sexual assault committed by the Respondent

VI. Other

Other

VI. Explain Other

VII. Marital Status and Divorce Proceedings

VII. If you are presently married (legally or by common-law), have you filed for Divorce?

Yes

VII. When was the Divorce filed

VII. Are TEMPORARY ORDERS or TEMPORARY RESTRAINING ORDERS in place, or a Hearing scheduled?

Yes

VII. If you were married to the Respondent in the past when was the divorce finalized?

VII. What is the current or finalized Divorce Case Cause Number?

VII. Who is or was your Attorney in the divorce case?

VII. In what county is or was your divorce case filed?

VIII. Your Income: (Are you receiving any Government entitlements, and if so, how much?)

VIII. TANF

VIII. Food Stamps

VIII. SSI

VIII. Child Support

VIII. Other

VIII. Gross Monthly Household Income

Form Page 5

X. Prohibited Locations and Minimum Distances

X. Are you requesting an order prohibiting the Respondent from going within a certain distance of you or a member of the household or family?

Yes

If so, list the person and/or places (include residence and work addresses, as well as children's schools or daycare, if applicable).

X. Name of Person 1

X. Relationship of Person 1

X. Address of Person 1

X. City of Person 1

X. State of Person 1

X. Name of Person 2

X. Relationship of Person 2

X. Address of Person 2

X. City of Person 2

X. State of Person 2

X. Name of Person 3

X. Relationship of Person 3

X. Address of Person 3

X. City of Person 3

X. State of Person 3

X. Name of Person 4

X. Relationship of Person 4

X. Address of Person 4

X. City of Person 4

X. State of Person 4

X. Name of Person 5

X. Relationship of Person 5

X. Address of Person 5

X. City of Person 5

X. State of Person 5

XI. Pets, Companion Animal or Assistance Animal

XI. Are you requesting an order prohibiting the Respondent from removing a pet, companion animal or assistance animal from your possession?

Yes

Form Page 8

List Past Incidents of Family Violence, even if no Police Report was Made

1. WHEN did the incident happen?

1. WHERE did the incident happen?

1. WHAT happened? (Describe any injuries AND on what part of the body they were suffered.)

1. Were the police called?

Yes

1. Witnesses: (Name, address, phone number)

2. WHEN did the incident happen?

2. WHERE did the incident happen?

2. WHAT happened? (Describe any injuries AND on what part of the body they were suffered.)

2. Were the police called?

Yes

2. Witnesses: (Name, address, phone number)

3. WHEN did the incident happen?

3. WHERE did the incident happen?

3. WHAT happened? (Describe any injuries AND on what part of the body they were suffered.)

3. Witnesses: (Name, address, phone number)

3. Were the police called?

Yes

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E-Mail Address:

Document Signers

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Nueces County, Texas