F.C.A. §§ 430, 550, 655, 828, 1029                                                  				 General Form 5      10/02  
ORI No:                                  	             		At a Term of the                                              Court
Order No: _______________	            			County of                                                                     , State of New York
NYSID  No:                             		  
            						    (address)                                                                                                                									                                                                                                                           

PRESENT:  Hon.                                                                  						TEMPORARY                        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:                                                        							‘ Ex Parte  
‘ Both Parties Present in Court 
v.											(check one)

Respondent  
Date of Birth:

NOTICE:  YOUR 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.  IF YOU FAIL TO APPEAR IN COURT WHEN YOU ARE REQUIRED TO SO, THIS ORDER MAY BE EXTENDED IN YOUR ABSENCE AND CONTINUE IN EFFECT UNTIL YOU APPEAR IN 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 good cause having been shown,

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 by mail, telephone, e-mail, voice-mail or other means with [specify                       protected persons(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] ‘ Temporary 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]                                                                                                              ; and 
Art. 8 only	 ‘  Pay to the petitioner/victim(s) restitution, as follows [specify terms]                                                                                                                                                                                                                     (amount up to $10,000); 

[99]  ‘	Observe such other condition(s) as are necessary to further the purposes of protection [specify conditions]:                                                                                                                                                                                                                                                                                                                                                                                                              ; 

         	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,  and/or   [13C] “ 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 temporary 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 (18 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
                 COURT (COURT SEAL) 
Check applicable box:    G   Personal service executed [specify date]:                                                                            
			 G   Order mailed on [specify date and to whom mailed ]:                                                         
 			 G   Order received by Respondent in Court [specify date]:                                                         
 			 G   Warrant issued for Respondent [specify date]: