Preview
RECElVED AND FILED '
14 .
,
0R RECORD
,I At
‘
O’ClockAM.
Cause No.: 2A D4 '
O4fi $4
APR 12 2021
Applicant: (\xhflQfl‘lQ
" Q\ O_nn lnthe A‘flfl fi H lsgicgirtm
I
er k
M0 tgom r ty,Texas
03V Deputy
mmmmmmm
Res’pondent: C yw IS¥OQ¥QF CW 041" m0 {gs 0 wry County, Texas
Application for Protective Order
1 Parties
Name: _
g
County of Residence:
Applicant: Cuflwwx @0‘n {\Amfloxnfl‘erol
Respondent. (‘\/\(. 5b PMQF Ga u A (“OM dameru
Respondent'saddressforservice: 306/? WQk meadow dr. mWJmM o.
“'X 7535’“!
'
Check aII that apply.
wThe Applicant and Respondent are or were members of the same family or household.
The Applicant and Respondent are parents of the same child or children.
D The Applicant and Respondent used to be married.
D The Applicant and Respondent are or were dating.
9/ The Applicant is an adult asking for protection for the Children named below from child abuse and/or
family or dating violence.
D The Applicant isdating or married to a person who was married to or dating the'Respondent.
2 Children: The Applicant is asking for protection for these Children under age 18:
Name. _
lsRespondent the biological parent? County of Residence:
a. 0Q {Mi G Q: fiYes D No ma/‘AQOW‘UJ
V
b. D Yes D No
c. U Yes D No
d. D Yes D No
Check all that apply:
ther children are listed on a sheet attached to this Application.
The Children are or were members of the Applicant's family or household.
D The Children are the subject of a court order affecting access to them or their support.
3 Other Adults: The Applicant isasking for protection for these Adults, who are or were members of the
Applicant's family or household, or are ina dating or marriage relationship with the Applicant.
Name: County of Residence:
a.
b.
4a Other Court Cases: Are there other court cases, like divorce,custody, support, involving the Applicant, Respondent,
or the Children?
D Yes fl No
"
lf“Yes, say what kind ofcase and the case
if is active or completed.
If“completed,” (check allthat apply): D A copy of the final orderisattached.
ElA copy of the finalorder willbe filedbefore the hearing on this Application.
a The Texas Office of the Attorney General Child Support Division has been
involved with a child support case. List the agency case number for each
open case, known. Case Number:
if
Application for Protective Order
Form Approved by the Supreme Court ofTexas Page 1 of 5
15
4b Presumption of FamilyViolence: Has the Respondent ever been convicted of or placed on deferred adjudication
community supervision for any crime under Title 5 or Title 6 of the Texas Penal Code? (see list of crimes at the end of the kit)
B(es mo
If“Yes,"say what kind of case:
Ifthe Respondent was convicted or placed on community supervision for a Title 5 crime, did the Court make a finding
that the crime involved family violence?
B(es Mo
Was the crime under Number 2 "Children"?
against a child listed in this petition
EYes Mo
Have the Respondent's parental rights to this child been terminated?
D{es o
lsthe Respondent seeking or attempting to seek contact with this child?
Wes D No
5 Grounds: Why is the Applicant asking for this Protective Order? Check one or both:
The Respondent committed family violence and is likely to commit family violence in the future.
D The Respondent violated a prior Protective Order that expired, or will expire in 30 days or less. A copy of the
Order is (check one): D Attached, or
D Not available now butwill be filed before the hearing on this Application
The Applicant requests a PROTECTIVE ORDER and asks the Court to make allOrders marked with a check 2’
6 VOrders to Prevent Family Violence
Theyplicant asks the Court to order the Respondent to (Check aII that apply):
a. otcommit family violence against any person named on page 1 of this form.
Not communicate in a threatening or harassing manner with any person named on page 1 of this form.
[\Jot communicate a threat through any person to any person named on page 1
99.6
.
of this form.
ot communicate or attempt to communicate in any manner with (Check all that apply):
Mpplicant E’Children D Other Adults named on page 1 of this form.
The Respondent may communicate through: 34 ”(1‘ Paiggfi AgQ or other person the Court
n?ent‘s
appoints. Good cause exists for prohibiting the Respon direct communications.
e. Q/Not go within 200 ya ds of the (Check allthat apply):
pplicant hildren D Other Adults named on page 1 of this form.
f.
yo within
Applicant
200 yards of the residence, workplace, or school of the (Check all that apply):
D Other Adults named on pagé 1 of this form.
g. Mot go within 200 yards of the Children's residence, child-care facility, or school, except as specifically
authorized ina possession schedule entered by the Court.
h. B/Not stalk, follow,or engage in conduct directed specifically to anyone named on page 1 of this form that
isreasonably harass, annoy,‘alarm, abuse, torment,
likely to or embarrass them.
Theycant asks the Court to:
i. uspend any license to carry a handgun issued to the Respondent by the State of Texas.
j. Require the Respondent to complete a battering intervention and prevention program; or if no such program is
available, counseling with a social worker, family service agency, physician, psychologist, licensed therapist, or
licensed professional counselor; and pay all costs forthe counseling or treatment ordered.
k. Prohibit the Respondent from taking, harming, threatening, or interfering with the care, custody, or control of the
following pet, companion animal, or assistance animal: (describe the
l. animal). Require the Respondent to follow these provisions to prevent or reduce the likelihood of family
violence:
6*qu qémmxibh Lekfibflmiafl mmk mM-ll/mmf/I
The law requires a trial court'fssuing a protective order to prohibit the Respondent from possessing a firefim or
ammunition, unless the Respondent is a peace officer actively engaged in employment as a sworn, fulI-time
paid employee of a state agency or political subdivision.
Application for Protective Order Page 2 of 5
Form Approved bytheSupreme Court of Texas
16
7 {Property Orders
The Residence located at: z ()0 [g “MM (“9,0an (gr mag? O‘ia T74 7755'”
(Check one): D owned or leased by the Applicant and Respondent;
is jointly
D issolely owned or leased by the Applicant; or
Ms solely owned or leased by the Respondent; and the Respondent is obligated to support the Applicant
or a childin the Applicant's possession.
The Applicant also asks the Court to make these orders (Check all that apply):
D The Applicant to have exclusive use of the Residence identified above, and the Respondent must vacate
the Residence.
El The sheriff,constable, or chief of police shall provide a law enforcement officer to accompany the Applicant to the
Residence, to inform the Respondent that the Court has ordered the Respondent excluded from the Residence, to
provide protection while the Applicant takes possession of the Residence and the Respondent removes any neces-
sary personal property. and, ifthe Respondent refuses to vacate the Residence, to remove the Respondent from
the Residence and arrest the Respondent for violating the Court's Order.
E1 The Applicant tohave exclusive use of the following property that the Applicant and Respondentjointly own or lease:
Mm Respondent must not damage,
leased by the parties, except in
transfer,encumber, or otherwise dispose of any propertyjointly owned or
the ordinary course of business or for reasonable and necessary livingexpenses,
including, but not limited to,removing or disabling ény vehicle owned or possessed by the Applicant orjointly
owned or possessed by the parties (whether so titled or not).
8 B Spousal Support Order _
The Applicant ismarried to the Respondent or otherwise legally entitled to support from the Respondent and asks
the Court to order the Respondent to pay support in an amount set by the Court.
9 m/Orders Related to Removal, Possession, and Support of Children
The Respondent is a parent of the following of the Applicant's children: D Gfl *4. G 01 n
And, the Applicant asks forthese Orders inthe best interest of the people named on page 1 of this form.
Ch ck all thatapply.
The Respondent must not remove the children from the Applicant's possession or from their child-care or
facility
E/school, except as specifically authorized in a possession schedule entered by the Court.
he Respondent must not remove the children from the jurisdiction of the Court.
Establish or modify a schedule for the Respondent‘s possession of the Children, subject to any terms and conditions
ecessary for the safety of the Applicant or the Children".
Require the Respondent to pay child support in an amount set by the Court.
10 Memporary Ex Parte PROTECTIVE ORDER
Based on the information in the attached Affidavit or Declaration, there is a clear and present danger of family violence
that will cause the Applicant, Children, or Other Adults named on page of this form immediate and irreparable injury,
‘I
loss, and damage, for which there is no adequate remedy at law. Applicant asks the Court to issue a Temporary Ex Parte <
Protective Order immediately without bond, notice, or hearing.
11 D Ex Parte Order: Vacate Residence Immediately
The Applicant now lives with the Respondent at: or has resided at this
Residence within the 30 days prior to filing this Application. The Respondent committed family violence against a
member of the household within the 30 days prior to the filing of this Application, as described in the attached
Affidavit or Declaration. There is a clear and present danger that the Respondent is likely to commit family violence
Application for Protective Order
Page 3 0f 5
Form Approved by theSupreme Courtof Texas
17
against a member of the household. The Applicant isavailable for a hearing but asks the Court to issue a Temporary
Ex Parte Protective Order immediately without bond, notice, or hearing:
« Granting the Applicant exclusive use and possession of the Residence and ordering the Respondent to vacate
the Residence immediately, and remain at least 200 yards away from the Residence pending further Order of the
Court; and
-
Directing the sheriff, constable, or chief of police to provide a law enforcement officer to accompany the Applicant
to the Residence, to inform the Respondent that the Court has ordered the Respondent to vacate the Residence,
and to provide protection while the Applicant either takes possession of the Residence or removes necessary
personal property.
12 (Keep Information Confidential
The Applicant asks the Court to keep addresses and telephone numbers for residences, workplaces, schools, and
childcare facilities confidential. The Applicant asks the Court to order the Court Clerk to strike contact information for
Protected People, including: addresses, mailing addresses, telephone numbers, places of employment, businesses,
child-care and schools from the public records of the Court. and maintain a confidential record of this
facilities,
information. The Applicants asks the Court to prohibit the Court Clerk from releasing contact information of
Protected People except to the Court or to law enforcement for the purpose of entering the information into the
Department of Public Safety law enforcement information system. The Applicant asks the Court to order that all
contact information of Protected People be confidential.
The Applicant asks the Court to order that the following person is designated as a person to receive any notice
or documents filed with the Court related to the Application on behalf of the Applicant:
Name: E (nflé #ing WQ‘VOAWU
Address. a lot VOrKJrom r MA NM ”Mu 1m. a c, ham 5'7 3
Mm Applicant asks the Court to order that the Applicant's address'Is confidential and shall only be disclosed to the
Court.
WARNING: A copy of this court document will be served to the respondent with any information that you include
available for public inspection. Marking the box on number 12 means that you are asking the judge to order the
clerk to remove some addresses and telephone numbers from the final order in this case so that the public cannot
see them. If you are requesting this. DO NOT INCLUDE this personal information in this form OR a temporary ex
‘parte protectiveorder form.
13'gkes And Costs
The Applicant asks the Court to order the Respondent topay fees for service of process. all other feesand costs of
Court, and reasonable attorneys” fees, ifapplicable.
|have read the entire Application and itistrue and correct to the best of my knowledge.
>Wm
Applicént Pro se
Oflw
AddresswhereAppIicantmax:ccontacted. E(VAQS Sfihfi. boflhqms
mot ‘l
Cour» Norw \QMW, Cm, 7»: ‘ny—n
Phone # where Applicant may be contacted: 3 (53 aLn, ‘07 ¢ Fax #:
(Listanother address/phone ifyou want yours kept confidential)
Application for Protective Order
Form Approved by the Supreme Court
of Texas Page 4of 5
18
Use form ifYOU
this WANT your Date of Birth
and Address to REMAIN CONFIDENTIAL.
AFFIDAVIT
'
You willneed tohave SIGNED BY A NOTARY.
it
County Of mon *9 O m Qrb‘l Do N_OT use the Declaration form
ifyou usethis form.
State of Texas
3—)
My name is Cq [Axm‘o‘xé V‘
C‘»
(FirstMiddle Last). | am years old and otherwise
competent to make The
this Affidavit. information and events described in thisAffidavit are true and correct.
1.Describe the most recent time the
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2. Inwhich county did this happen? an} omsrvl nasd
3.What date did thishappen? (29 laim
4. Was a weapon involved? D Yes E/No Ifyes, what kind?
5.Were any children there? es D No Ifyes, who?
6.Did anyone callthe police? D Yes EVI( Ifyes, what happened?
7.Did you get medical care? Ye N Ifyes, describe your injuries:
8.Has the Respondent ever threatened or hurt you before? Describe below in detailhow the Respondent threatened 0|
hurt you, including date(s) ifpossible.
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11. Have the police ever been called? fies [j No
12. Didyou ever have to get medical care? [1Yes p’No lfyes, describe your injuries:
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13.Has the Defendant ever been convicted of family violence? D Yes
Ifyes, list when and in which county and state the convictions occurred:
1 A~>“§.‘v"é"r>, JAN ET ROBERTS
'
53,.“ 9o: Notary Texas
Public. State of
"ea,_. .
~ . Irs 11-07-2022
éfiififig Notary ID 128327791 .
>
’
.
,
ApplicaMéllgns here
On OH / OE I‘M'Zl the Applicant
personally appeared before me, the unde igned notary. After being
sworn, the Applicant stated that she/he
isqualified tomake this
‘
oath, that she/hehas read the foregoing Application and Affidavit,
that she/hehas personal knowledge of the facts asserted, and the public m and for the State ofTexas
and
facts asserted are true knowledge and
to the best of her/his
belief.Subscribed and sworn before me on Qfl I(1% IZQZI .
La - [3:]! 31238
_ , _
My CommISSIon explres:
Application for Protective Order Page 5 of 5
Form Approved by the Supreme Court
of Texas
Preview
RECElVED AND FILED ' 14 . , 0R RECORD ,I At ‘ O’ClockAM. Cause No.: 2A D4 ' O4fi $4 APR 12 2021 Applicant: (\xhflQfl‘lQ " Q\ O_nn lnthe A‘flfl fi H lsgicgirtm I er k M0 tgom r ty,Texas 03V Deputy mmmmmmm Res’pondent: C yw IS¥OQ¥QF CW 041" m0 {gs 0 wry County, Texas Application for Protective Order 1 Parties Name: _ g County of Residence: Applicant: Cuflwwx @0‘n {\Amfloxnfl‘erol Respondent. (‘\/\(. 5b PMQF Ga u A (“OM dameru Respondent'saddressforservice: 306/? WQk meadow dr. mWJmM o. “'X 7535’“! ' Check aII that apply. wThe Applicant and Respondent are or were members of the same family or household. The Applicant and Respondent are parents of the same child or children. D The Applicant and Respondent used to be married. D The Applicant and Respondent are or were dating. 9/ The Applicant is an adult asking for protection for the Children named below from child abuse and/or family or dating violence. D The Applicant isdating or married to a person who was married to or dating the'Respondent. 2 Children: The Applicant is asking for protection for these Children under age 18: Name. _ lsRespondent the biological parent? County of Residence: a. 0Q {Mi G Q: fiYes D No ma/‘AQOW‘UJ V b. D Yes D No c. U Yes D No d. D Yes D No Check all that apply: ther children are listed on a sheet attached to this Application. The Children are or were members of the Applicant's family or household. D The Children are the subject of a court order affecting access to them or their support. 3 Other Adults: The Applicant isasking for protection for these Adults, who are or were members of the Applicant's family or household, or are ina dating or marriage relationship with the Applicant. Name: County of Residence: a. b. 4a Other Court Cases: Are there other court cases, like divorce,custody, support, involving the Applicant, Respondent, or the Children? D Yes fl No " lf“Yes, say what kind ofcase and the case if is active or completed. If“completed,” (check allthat apply): D A copy of the final orderisattached. ElA copy of the finalorder willbe filedbefore the hearing on this Application. a The Texas Office of the Attorney General Child Support Division has been involved with a child support case. List the agency case number for each open case, known. Case Number: if Application for Protective Order Form Approved by the Supreme Court ofTexas Page 1 of 5 15 4b Presumption of FamilyViolence: Has the Respondent ever been convicted of or placed on deferred adjudication community supervision for any crime under Title 5 or Title 6 of the Texas Penal Code? (see list of crimes at the end of the kit) B(es mo If“Yes,"say what kind of case: Ifthe Respondent was convicted or placed on community supervision for a Title 5 crime, did the Court make a finding that the crime involved family violence? B(es Mo Was the crime under Number 2 "Children"? against a child listed in this petition EYes Mo Have the Respondent's parental rights to this child been terminated? D{es o lsthe Respondent seeking or attempting to seek contact with this child? Wes D No 5 Grounds: Why is the Applicant asking for this Protective Order? Check one or both: The Respondent committed family violence and is likely to commit family violence in the future. D The Respondent violated a prior Protective Order that expired, or will expire in 30 days or less. A copy of the Order is (check one): D Attached, or D Not available now butwill be filed before the hearing on this Application The Applicant requests a PROTECTIVE ORDER and asks the Court to make allOrders marked with a check 2’ 6 VOrders to Prevent Family Violence Theyplicant asks the Court to order the Respondent to (Check aII that apply): a. otcommit family violence against any person named on page 1 of this form. Not communicate in a threatening or harassing manner with any person named on page 1 of this form. [\Jot communicate a threat through any person to any person named on page 1 99.6 . of this form. ot communicate or attempt to communicate in any manner with (Check all that apply): Mpplicant E’Children D Other Adults named on page 1 of this form. The Respondent may communicate through: 34 ”(1‘ Paiggfi AgQ or other person the Court n?ent‘s appoints. Good cause exists for prohibiting the Respon direct communications. e. Q/Not go within 200 ya ds of the (Check allthat apply): pplicant hildren D Other Adults named on page 1 of this form. f. yo within Applicant 200 yards of the residence, workplace, or school of the (Check all that apply): D Other Adults named on pagé 1 of this form. g. Mot go within 200 yards of the Children's residence, child-care facility, or school, except as specifically authorized ina possession schedule entered by the Court. h. B/Not stalk, follow,or engage in conduct directed specifically to anyone named on page 1 of this form that isreasonably harass, annoy,‘alarm, abuse, torment, likely to or embarrass them. Theycant asks the Court to: i. uspend any license to carry a handgun issued to the Respondent by the State of Texas. j. Require the Respondent to complete a battering intervention and prevention program; or if no such program is available, counseling with a social worker, family service agency, physician, psychologist, licensed therapist, or licensed professional counselor; and pay all costs forthe counseling or treatment ordered. k. Prohibit the Respondent from taking, harming, threatening, or interfering with the care, custody, or control of the following pet, companion animal, or assistance animal: (describe the l. animal). Require the Respondent to follow these provisions to prevent or reduce the likelihood of family violence: 6*qu qémmxibh Lekfibflmiafl mmk mM-ll/mmf/I The law requires a trial court'fssuing a protective order to prohibit the Respondent from possessing a firefim or ammunition, unless the Respondent is a peace officer actively engaged in employment as a sworn, fulI-time paid employee of a state agency or political subdivision. Application for Protective Order Page 2 of 5 Form Approved bytheSupreme Court of Texas 16 7 {Property Orders The Residence located at: z ()0 [g “MM (“9,0an (gr mag? O‘ia T74 7755'” (Check one): D owned or leased by the Applicant and Respondent; is jointly D issolely owned or leased by the Applicant; or Ms solely owned or leased by the Respondent; and the Respondent is obligated to support the Applicant or a childin the Applicant's possession. The Applicant also asks the Court to make these orders (Check all that apply): D The Applicant to have exclusive use of the Residence identified above, and the Respondent must vacate the Residence. El The sheriff,constable, or chief of police shall provide a law enforcement officer to accompany the Applicant to the Residence, to inform the Respondent that the Court has ordered the Respondent excluded from the Residence, to provide protection while the Applicant takes possession of the Residence and the Respondent removes any neces- sary personal property. and, ifthe Respondent refuses to vacate the Residence, to remove the Respondent from the Residence and arrest the Respondent for violating the Court's Order. E1 The Applicant tohave exclusive use of the following property that the Applicant and Respondentjointly own or lease: Mm Respondent must not damage, leased by the parties, except in transfer,encumber, or otherwise dispose of any propertyjointly owned or the ordinary course of business or for reasonable and necessary livingexpenses, including, but not limited to,removing or disabling ény vehicle owned or possessed by the Applicant orjointly owned or possessed by the parties (whether so titled or not). 8 B Spousal Support Order _ The Applicant ismarried to the Respondent or otherwise legally entitled to support from the Respondent and asks the Court to order the Respondent to pay support in an amount set by the Court. 9 m/Orders Related to Removal, Possession, and Support of Children The Respondent is a parent of the following of the Applicant's children: D Gfl *4. G 01 n And, the Applicant asks forthese Orders inthe best interest of the people named on page 1 of this form. Ch ck all thatapply. The Respondent must not remove the children from the Applicant's possession or from their child-care or facility E/school, except as specifically authorized in a possession schedule entered by the Court. he Respondent must not remove the children from the jurisdiction of the Court. Establish or modify a schedule for the Respondent‘s possession of the Children, subject to any terms and conditions ecessary for the safety of the Applicant or the Children". Require the Respondent to pay child support in an amount set by the Court. 10 Memporary Ex Parte PROTECTIVE ORDER Based on the information in the attached Affidavit or Declaration, there is a clear and present danger of family violence that will cause the Applicant, Children, or Other Adults named on page of this form immediate and irreparable injury, ‘I loss, and damage, for which there is no adequate remedy at law. Applicant asks the Court to issue a Temporary Ex Parte < Protective Order immediately without bond, notice, or hearing. 11 D Ex Parte Order: Vacate Residence Immediately The Applicant now lives with the Respondent at: or has resided at this Residence within the 30 days prior to filing this Application. The Respondent committed family violence against a member of the household within the 30 days prior to the filing of this Application, as described in the attached Affidavit or Declaration. There is a clear and present danger that the Respondent is likely to commit family violence Application for Protective Order Page 3 0f 5 Form Approved by theSupreme Courtof Texas 17 against a member of the household. The Applicant isavailable for a hearing but asks the Court to issue a Temporary Ex Parte Protective Order immediately without bond, notice, or hearing: « Granting the Applicant exclusive use and possession of the Residence and ordering the Respondent to vacate the Residence immediately, and remain at least 200 yards away from the Residence pending further Order of the Court; and - Directing the sheriff, constable, or chief of police to provide a law enforcement officer to accompany the Applicant to the Residence, to inform the Respondent that the Court has ordered the Respondent to vacate the Residence, and to provide protection while the Applicant either takes possession of the Residence or removes necessary personal property. 12 (Keep Information Confidential The Applicant asks the Court to keep addresses and telephone numbers for residences, workplaces, schools, and childcare facilities confidential. The Applicant asks the Court to order the Court Clerk to strike contact information for Protected People, including: addresses, mailing addresses, telephone numbers, places of employment, businesses, child-care and schools from the public records of the Court. and maintain a confidential record of this facilities, information. The Applicants asks the Court to prohibit the Court Clerk from releasing contact information of Protected People except to the Court or to law enforcement for the purpose of entering the information into the Department of Public Safety law enforcement information system. The Applicant asks the Court to order that all contact information of Protected People be confidential. The Applicant asks the Court to order that the following person is designated as a person to receive any notice or documents filed with the Court related to the Application on behalf of the Applicant: Name: E (nflé #ing WQ‘VOAWU Address. a lot VOrKJrom r MA NM ”Mu 1m. a c, ham 5'7 3 Mm Applicant asks the Court to order that the Applicant's address'Is confidential and shall only be disclosed to the Court. WARNING: A copy of this court document will be served to the respondent with any information that you include available for public inspection. Marking the box on number 12 means that you are asking the judge to order the clerk to remove some addresses and telephone numbers from the final order in this case so that the public cannot see them. If you are requesting this. DO NOT INCLUDE this personal information in this form OR a temporary ex ‘parte protectiveorder form. 13'gkes And Costs The Applicant asks the Court to order the Respondent topay fees for service of process. all other feesand costs of Court, and reasonable attorneys” fees, ifapplicable. |have read the entire Application and itistrue and correct to the best of my knowledge. >Wm Applicént Pro se Oflw AddresswhereAppIicantmax:ccontacted. E(VAQS Sfihfi. boflhqms mot ‘l Cour» Norw \QMW, Cm, 7»: ‘ny—n Phone # where Applicant may be contacted: 3 (53 aLn, ‘07 ¢ Fax #: (Listanother address/phone ifyou want yours kept confidential) Application for Protective Order Form Approved by the Supreme Court of Texas Page 4of 5 18 Use form ifYOU this WANT your Date of Birth and Address to REMAIN CONFIDENTIAL. AFFIDAVIT ' You willneed tohave SIGNED BY A NOTARY. it County Of mon *9 O m Qrb‘l Do N_OT use the Declaration form ifyou usethis form. State of Texas 3—) My name is Cq [Axm‘o‘xé V‘ C‘» (FirstMiddle Last). | am years old and otherwise competent to make The this Affidavit. information and events described in thisAffidavit are true and correct. 1.Describe the most recent time the 050/) 019(I\ QAJQ¥ 5% 102$ 31’5OQN‘ 0M6~50mA R th‘s spondent hurt you or threatened to hurt you. Came “IA a anJ Ewen 1)»qu Spr‘mq d? +l> Vim mefl- hm‘I Vetting )vrafd ghoul, WA damper 0A Mu {am ‘f Lou \nth W“ ww CM“ {om NM Hi" AJl—oeflwv-n— nah; J homz w P/ormdra W“) *O‘fluvya‘ 1V1“ Knita‘ me m buck Lo {N n‘féw 50A S'wvhrxyb(oufima rh’r 5 )Mo thfiicew 2. Inwhich county did this happen? an} omsrvl nasd 3.What date did thishappen? (29 laim 4. Was a weapon involved? D Yes E/No Ifyes, what kind? 5.Were any children there? es D No Ifyes, who? 6.Did anyone callthe police? D Yes EVI( Ifyes, what happened? 7.Did you get medical care? Ye N Ifyes, describe your injuries: 8.Has the Respondent ever threatened or hurt you before? Describe below in detailhow the Respondent threatened 0| hurt you, including date(s) ifpossible. Ofl 39% Came home k “\£\ WUQMIM W\ovc\n V‘Ubo‘i‘q VLOlen+ @Calm he, \Wim GA} c010 \fii Sh'r‘ne M 61km +0 QIQM k ano‘ kom: L'cx'wd W12 Prawn! Me thah“ 4Men lWth .Amp w flfir/l &m,J/\ PrWoprJzJ bx! ans; 9: «)0 Wm M3 MA N \;\M \mx ax 1mm” 0m \nz \elfign Mme» Mm cm”. \“eQ/Kpojzc‘ *71/ ra‘o/‘ALJ RuM \ni-S KOO§LA Mvave \Yu Sn: Wk: €40 nmr‘ Cwek 9V?“weapons ere M 5C: x \, ever In am olvea‘? 0,1 m1 u an Yesfl No "3“ If N5 yes \Qmsv.’ mil what kind? a J fira‘om'd 0W“! mar 15m “wane iamsg 10. Were any children there? M’Yes E} No Ifyes, who? nowvzi G 0\-/\ 11. Have the police ever been called? fies [j No 12. Didyou ever have to get medical care? [1Yes p’No lfyes, describe your injuries: W W 13.Has the Defendant ever been convicted of family violence? D Yes Ifyes, list when and in which county and state the convictions occurred: 1 A~>“§.‘v"é"r>, JAN ET ROBERTS ' 53,.“ 9o: Notary Texas Public. State of "ea,_. . ~ . Irs 11-07-2022 éfiififig Notary ID 128327791 . > ’ . , ApplicaMéllgns here On OH / OE I‘M'Zl the Applicant personally appeared before me, the unde igned notary. After being sworn, the Applicant stated that she/he isqualified tomake this ‘ oath, that she/hehas read the foregoing Application and Affidavit, that she/hehas personal knowledge of the facts asserted, and the public m and for the State ofTexas and facts asserted are true knowledge and to the best of her/his belief.Subscribed and sworn before me on Qfl I(1% IZQZI . La - [3:]! 31238 _ , _ My CommISSIon explres: Application for Protective Order Page 5 of 5 Form Approved by the Supreme Court of Texas