Form EA-100 Request for Elder or Dependent Adult Abuse Restraining Orders - California

Form EA-100 or the "Request For Elder Or Dependent Adult Abuse Restraining Orders" is a form issued by the California Courts.

The form was last revised in January 1, 2018 and is available for digital filing. Download an up-to-date Form EA-100 in PDF-format down below or look it up on the California Courts Forms website.

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Request for Elder or Dependent
Clerk stamps date here when form is filed.
EA-100
Adult Abuse Restraining Orders
Read Can an Elder or Dependent Adult Abuse Restraining Order Help Me?
(form EA-100-INFO) before completing this form. Also fill out Confidential
CLETS Information (form CLETS-001) with as much information as you
know.
Elder or Dependent Adult in Need of Protection
1
Full Name:
Sex:
M
F
Age:
Fill in court name and street address:
Person From Whom Protection Is Sought
2
Superior Court of California, County of
Full Name:
Address (if known):
City:
State:
Zip:
Person Requesting Order
3
Court fills in case number when form is filed.
Who is asking the court for protection? (Check a, b, or c):
Case Number:
a.
The elder or dependent adult named in
.
1
b.
Name:
conservator of the
person
estate
person and estate
1
of the person named in
, appointed by (name of court):
Case No.:
(name)
c.
Other
(Show this person’s legal authority to make this request on an attached sheet of paper. Write “Attachment
3c—Information About Person Requesting Protective Order” for a title. You may use form MC-025,
Attachment.)
Contact Information
4
Contact information for the person asking the court for protection
a.
Your Lawyer (if you have one for this case)
Name:
State Bar No.:
Firm Name:
b. Your Address (If you have a lawyer, give your lawyer’s information. If you do not have a lawyer and want to
keep your home address private, you may give a different mailing address instead. The person in
1
does not
have to give telephone, fax, or e-mail.)
Address:
City:
State:
Zip:
Telephone:
Fax:
E-Mail Address:
This is not a Court Order.
Judicial Council of California, www.courts.ca.gov
Request for Elder or Dependent Adult Abuse
EA-100,
Page 1 of 8
Revised January 1, 2018, Mandatory Form
Welfare & Institutions Code, § 15657.03
Restraining Orders
Code of Civil Procedure, § 527.9
(Elder or Dependent Adult Abuse Prevention)
Request for Elder or Dependent
Clerk stamps date here when form is filed.
EA-100
Adult Abuse Restraining Orders
Read Can an Elder or Dependent Adult Abuse Restraining Order Help Me?
(form EA-100-INFO) before completing this form. Also fill out Confidential
CLETS Information (form CLETS-001) with as much information as you
know.
Elder or Dependent Adult in Need of Protection
1
Full Name:
Sex:
M
F
Age:
Fill in court name and street address:
Person From Whom Protection Is Sought
2
Superior Court of California, County of
Full Name:
Address (if known):
City:
State:
Zip:
Person Requesting Order
3
Court fills in case number when form is filed.
Who is asking the court for protection? (Check a, b, or c):
Case Number:
a.
The elder or dependent adult named in
.
1
b.
Name:
conservator of the
person
estate
person and estate
1
of the person named in
, appointed by (name of court):
Case No.:
(name)
c.
Other
(Show this person’s legal authority to make this request on an attached sheet of paper. Write “Attachment
3c—Information About Person Requesting Protective Order” for a title. You may use form MC-025,
Attachment.)
Contact Information
4
Contact information for the person asking the court for protection
a.
Your Lawyer (if you have one for this case)
Name:
State Bar No.:
Firm Name:
b. Your Address (If you have a lawyer, give your lawyer’s information. If you do not have a lawyer and want to
keep your home address private, you may give a different mailing address instead. The person in
1
does not
have to give telephone, fax, or e-mail.)
Address:
City:
State:
Zip:
Telephone:
Fax:
E-Mail Address:
This is not a Court Order.
Judicial Council of California, www.courts.ca.gov
Request for Elder or Dependent Adult Abuse
EA-100,
Page 1 of 8
Revised January 1, 2018, Mandatory Form
Welfare & Institutions Code, § 15657.03
Restraining Orders
Code of Civil Procedure, § 527.9
(Elder or Dependent Adult Abuse Prevention)
Case Number:
Description of Protected Person
5
1
The person named in
(check a or b):
a.
Is age 65 or older and a resident of California.
b.
Is a resident of California and an adult under age 65. This person has physical or mental limitations that
restrict his or her ability to carry out normal activities or to protect his or her rights. (Briefly describe
limitations on the attached sheet of paper or form MC-025. Write “Attachment 5b—Description of
Protected Person” for a title.)
Additional Protected Persons
6
a. Are you asking for protection for any other family or household members or for the conservator of the elder or
Yes
No
(If yes, list them):
dependent adult listed in
1
?
Full Name
Sex
Age
Lives with you? How are they related to you?
Yes
No
Yes
No
Yes
No
Yes
No
Check here if there are more persons. Attach a sheet of paper and write “Attachment 6a—Additional Protected
Persons” for a title. You may use form MC-025, Attachment.
b.
Why do these people need protection? (Explain below):
Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of
paper or form MC-025 and write “Attachment 6b—Why Others Need Protection” for a title.
Relationship of Parties
7
How does the person in
1
know the person in
2
? (Explain below):
Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of
paper or form MC-025 and write “Attachment 7—Relationship of Parties” for a title.
Venue
8
Why are you filing in this county? (Check all that apply):
a.
The person in
2
lives in this county.
1
The person in
was abused by the person in
in this county.
b.
2
c.
Other (specify):
This is not a Court Order.
Revised January 1, 2018
Request for Elder or Dependent Adult Abuse
EA-100,
Page 2 of 8
Restraining Orders
(Elder or Dependent Adult Abuse Prevention)
Case Number:
Other Court Cases
9
a. Has the person in
1
6
or any of the persons named in
been involved in another court case with the person in
No
Yes
(If yes, specify the kind of each case and indicate where and when each was filed):
2
?
Kind of Case
Filed in (County/State)
Year Filed Case Number (if known)
(1)
Elder or Dependent Adult Abuse
(2)
Civil Harassment
(3)
Domestic Violence
(4)
Divorce, Nullity, Legal Separation
(5)
Paternity, Parentage, Child Custody
(6)
Eviction
(7)
Guardianship
(8)
Workplace Violence
(9)
Small Claims
(10)
Criminal
(11)
Other (specify):
b. Are there now any protective or restraining orders in effect relating to the person in
or any of the persons
1
named in
and the person in
?
No
Yes
(If yes, attach a copy if you have one.)
6
2
Description of Abuse
10
a. Abuse means either:
(1)
Physical abuse, neglect, financial abuse, abandonment, isolation, abduction, or other treatment with
resulting physical harm or pain or mental suffering; or
(2) The withholding by a caretaker of goods or services that are necessary to avoid physical harm or mental
suffering.
b.
Tell the court about the last time the person in
2
abused the person in
1
.
(1)
When did it happen? (Provide date or estimated date):
(2) Who else was there?
(3)
Describe what happened below.
Check here if there is not enough space for your answer. Put your complete answer on the attached
sheet of paper or form MC-025 and write “Attachment 10b(3)—Describe Abuse” for a title.
(4)
Was the abuse solely financial abuse unaccompanied by force, threat, harassment, intimidation, or any
other form of abuse?
Yes, only financial abuse.
No, the abuse included other forms of abuse described above.
This is not a Court Order.
Revised January 1, 2018
Request for Elder or Dependent Adult Abuse
EA-100,
Page 3 of 8
Restraining Orders
(Elder or Dependent Adult Abuse Prevention)
Case Number:
b.
(5)
Did the person in
use or threaten to use a gun or any other weapon?
2
10
Yes
No
(If yes, explain below):
Check here if there is not enough space for your answer. Put your complete answer on the attached
sheet of paper or form MC-025 and write “Attachment 10b(5)—Use of Weapons” for a title.
(6)
Was the person in
harmed or injured as a result of the acts of abuse described above?
1
Yes
No
(If yes, explain below):
Check here if there is not enough space for your answer. Put your complete answer on the attached
sheet of paper or form MC-025 and write “Attachment 10b(6)—Harm or Injury” for a title.
(7)
Did the police come?
Yes
No
If yes, did they give the person in
1
or the person in
2
an Emergency Protective Order?
Yes
No
If yes, the order protects (check all that apply):
the person in
the person in
2
the persons in
6
.
1
(Attach a copy of the order if you have one.)
c.
Is the person in
a care custodian who deprived the person in
of (kept from him or her, did not allow him
2
1
2
1
or her to have or receive, or did not provide him or her with) goods or services that the person needed to avoid
physical harm or mental suffering?
Yes
No
(If yes, describe below what the person was deprived of and how that affected him or her):
Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of
paper or form MC-025 and write “Attachment 10c—Deprivation by Care Custodian” for a title.
d.
Has the person in
2
abused the person in
1
at other times?
Yes
No
(If yes, describe prior incidents and provide dates below):
Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of
paper or form MC-025 and write “Attachment 10d—Previous Abuse” for a title.
This is not a Court Order.
Revised January 1, 2018
Request for Elder or Dependent Adult Abuse
EA-100,
Page 4 of 8
Restraining Orders
(Elder or Dependent Adult Abuse Prevention)
Case Number:
þ
Check the orders you want.
Personal Conduct Orders
11
I ask the court to order the person in
not to do any of the following things to the person in
or to any person
2
1
to be protected listed in
:
6
a.
Physically abuse, financially abuse, intimidate, molest, attack, strike, stalk, threaten, assault (sexually or
otherwise), hit, harass, destroy the personal property of, or disturb the peace of the person.
b.
Contact the person, either directly or indirectly, in any way, including, but not limited to, in person, by
telephone, in writing, by public or private mail, by interoffice mail, by e-mail, by text message, by fax, or by
other electronic means.
c.
Other (specify):
Check here if there is not enough space for your answer. Put your complete answer on the attached
sheet of paper or form MC-025 and write “Attachment 11c—Other Personal Conduct Orders,” for a
title.
The person in
will be ordered not to take any action to get the addresses or locations of any protected person
2
unless the court finds good cause not to make the order.
Stay-Away Orders
12
a.
I ask the court to order the person in
2
to stay at least
yards away from (check all that apply):
(1)
The elder or dependent adult in
.
1
1
(2)
The persons in
.
6
6
(3)
The home of the elder or dependent adult.
(4)
The job or workplace of the elder or dependent adult.
(5)
The vehicle of the elder or dependent adult.
(6)
Other (specify):
b.
If the court orders the person in
2
to stay away from all the places listed above, will he or she still be able to
2
get to his or her home, school, or job?
(If no, explain below):
Yes
No
Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of
paper or form MC-025 and write “Attachment 12b—Stay-Away Orders,” for a title.
This is not a Court Order.
Revised January 1, 2018
Request for Elder or Dependent Adult Abuse
EA-100,
Page 5 of 8
Restraining Orders
(Elder or Dependent Adult Abuse Prevention)

Download Form EA-100 Request for Elder or Dependent Adult Abuse Restraining Orders - California

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