F.C.A. 446, 551, 656, 842 & 1056							 General  Form 5a      10/02
ORI No:                                                        	At a Term of the                                                                  Court
Order No:                                                     	County of                                                                  ,State of New York
NYSID No:-                                                   	(address)                                                                                                     
			                                                                                                                    PRESENT: Hon.		ORDER OF PROTECTION
                                                                                                                         	[Articles 4, 5, 6, 8 and 10]
In the Matter of a Proceeding under
Article                             Of the Family Court Act	

				Docket No.                                                    
Petitioner			Family Unit No.                                            
Date of Birth:		  Upon Default
		v.		  Both Parties Present In Court
			(check one)
Respondent
Date of Birth:

NOTICE: YOUR WILLFUL FAILURE TO OBEY THIS ORDER MAY SUBJECT YOU TO MANDATORY ARREST AND CRIMINAL PROSECUTION, WHICH MAY RESULT IN YOUR INCARCERATION FOR UP TO SEVEN YEARS FOR CRIMINAL CONTEMPT, AND/OR MAY SUBJECT YOU TO FAMILY COURT PROSECUTION AND INCARCERATION  FOR UP TO SIX MONTHS FOR CONTEMPT OF COURT.                                                                                                                

	A petition under Article    of the Family Court Act, sworn to on                                      ,   having been filed in this Court in the above-entitled proceeding, and  [check applicable box]:  after hearing     on consent ,
	Now, therefore,  it is hereby ordered that  [specify first name, middle initial and last name]:                                                                                                 observe the following conditions of behavior:
(Check Applicable Paragraphs and Subparagraphs)
[01] 	Stay away from [A]  (name(s) of protected persons)                                                                                         ; and/or from the               [B]  home of                                                                    , [C]   school of                                                                              ,
	[D]  business of                                                               , [E]   place of employment of                                                        ,	[F]   other [specify location]                                                                                                                                                           
[14  Refrain from communication or any other contact or by mail, telephone, e-mail, voice-mail or other means with [specify                            protected person(s)]:                                                                                                                                                                          ;    
[02]  Refrain from assault, stalking, harassment, menacing, reckless endangerment, disorderly conduct, intimidation, threats  or any                 criminal offense against [specify protected person(s) and/or, members of protected person's family or household, and/or                            person(s) with  custody of child(ren)]:                                                                                                                                              ;

[11]  Permit [specify individual]:                                                               to enter the residence at [specify]:                                                                                                                         during [specify date/time]:                                                         with [specify law                          enforcement agency, if any]:                                             to remove personal belongings not in issue in  litigation [specify items]:                                                                                                                                                                ;

[04]  	Refrain from [indicate acts]:                                                                                                                                                                           that create an unreasonable risk to the health, safety or welfare of [specify child(ren), family or household member(s) ]:                                                                                                                                                                                                                                     ;

[05]  	Permit [specify individual]:                                                                      , entitled by a court order or separation or other written               agreement to visit with [specify child(ren)]:                                                                                                     during the following               periods of time [specify]:                                                                                 under the following terms and conditions [specify]:                                                                                                                                                                                                                       ; 
[07] 	Custody of [specify child(ren)]:                                                                                                                      shall be awarded to 	[specify individual]:                                                           under the  following  terms and conditions  [specify]:                                                                                                                                                                                                                                                  ; 
[12]  	Surrender any and all handguns, pistols, revolvers, rifles, shotguns and other firearms owned or possessed, including, but not                    limited to, the  following:                                                                                                                                                                                 Such surrender shall take place immediately, but in no event later than [specify date/time]:                                                                          at [specify location]:                                                                                                                                                                       ;
 
        	Pay or provide access to health or medical insurance for necessary medical care and treatment arising from the incident or                         incidents forming the basis of the order [specify beneficiary of treatment and coverage]                                                                                                                                                                                                                                                                                      ;  
Arts. 5,6&8 only    Pay counsel fees (and/or) any costs associated with the order to [specify person and terms]                                                                                                                                                                                                                                                             ;   
Arts. 4,5&6 only    Participate in an educational program, (and pay the costs thereof)[(specify program]                                                                                                                                                                                                                                                                       ;  Art. 8 only              Participate in a batterer's education program designed to help end violent behavior (and pay the costs  	thereof)[specify  program]                                                                                                                                                             ;
Art. 8 only	        Pay to the petitioner/victim(s) restitution, as follows [specify terms and amount up to $1 0,000]:                             	                                                                                                                                                                                            ;  and
[99]          Observe such other condition(s) as are necessary to further the purposes of protection [specify conditions]: 	                                                                                                                                                                                                                                                                                                                                                                                                                               .
Art. 8 only [check if applicable]:   Respondent is on  probation [FCA§842 requires order to indicate if Respondent is on probation].
		
Finding of Aggravated Circumstances
[check box and fill in if applicable]
                The court has made a finding on the record of the existence of the following AGGRAVATING CIRCUMSTANCES: 
                                                                                                                                                                                                                                                                                                                                                                                                                                                  It is further ordered that the above-named Respondent's license to carry, possess, repair, sell or otherwise dispose of a  firearm or firearms, if any, pursuant to Penal Law§400.00, is hereby [13A]  suspended  or    [13B]  revoked,  and/or  [I3C] the Respondent shall remain ineligible to receive a firearm license during the period of this order. (Check all  applicable boxes).

It is further ordered that this order of protection shall remain in effect until [specify date]:                                                     .
	
The Family Court Act provides that presentation of a copy of this order of protection to any police officer or peace officer acting pursuant to his or her special duties shall authorize, and in some situations may require, such officer to arrest a person who is alleged to have violated its terms and to bring him or her before the court to face whatever penalties may be imposed therefor.
Federal law provides that this order must be honored and enforced by state and tribal courts, including courts of a state, the District of Columbia; a commonwealth, territory or possession of the United States, if it is established that the person against whom the order is sought has or will be afforded reasonable notice and opportunity to be heard in accordance with state law sufficient to protect that person's rights (I 8 U. S.C. §§ 2265, 2266).   
It is a federal offense to:  cross state lines to violate an order of protection; cross state lines  to engage in stalking, harassment or domestic violence against an intimate partner or family member;  possess,  purchase, ship, transfer or receive a handgun,  rifle, shotgun or other firearm or ammunition  following a conviction of a domestic violence misdemeanor involving the use or attempted use of physical force or a deadly weapon;  or (except for military or law enforcement officers while on duty) possess, purchase, ship, transfer or receive a handgun,  rifle, shotgun or other firearm or ammunition while an order of protection, issued after notice and an opportunity to be heard, that protects an intimate partner against assault, harassment, threatening and/or stalking, remains in effect (18 U.S.C. ''922(g)(8), 922(g)(9), 2261, 2261A,  2262).

PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF COURT, OR 30 DAYS AFTER  SERVICE BY A PARTY OR THE LAW GUARDIAN UPON THE APPELLANT, WHICHEVER IS EARLIEST.
				ENTER

Dated:         ,    .    		                                                                                    
				       JUDGE/JUSTICE
Check applicable box:			             COURT (COURT SEAL) 
   Personal service executed [specify date(s)]:                                                                               
   Order mailed on [specify date(s) and to whom mailed ]:                                                            
   Order received by Respondent in court on [specify date(s)]:                                                      
  Warrant issued for Respondent [specify date]: