Stanislaus — Request for Elder or Dependent Adult Abuse Restraining Order Packet

Source: https://www.stanislaus.courts.ca.gov/system/files/forms-and-filings/elder-abuse.pdf

Sparse pages use OCR; original PDF remains authoritative.

www.stanislaus.courts.ca.gov Street Address: 1100 I Street, Modesto, CA 95353 Mailing Address: P.O. Box 1098, Modesto, CA 95354 Self Help Center: 800 11th Street, Room 220, Modesto, CA 95353 (PROVIDING ASSISTANCE TO PARTIES REPRESENTING THEMSELVES)

Revised 1/2025

REQUEST FOR ELDER OR DEPENDENT ADULT ABUSE RESTRAINING ORDER PACKET

All documents must be typed or printed legibly per Rules of Court 2.104, in blue or black ink.

This packet includes the necessary forms to file a Request for Elder or Dependent Adult Abuse restraining order.

Judicial Council forms, local forms and information are available in the Clerk’s Office, the Stanislaus County Law Library located at 1101 13th Street, Modesto, and on the following Websites:

Stanislaus County Superior Court: www.stanislaus.courts.ca.gov Judicial Council’s Self Help: www.selfhelp.courts.ca.gov Judicial Council Forms: www.courts.ca.gov/forms-rules/find-your-court-forms

REQUIRED FORMS: CLETS-001 - Confidential CLETS Information EA-100 - Request for Orders to Stop Elder or Dependent Adult Abuse EA-110 - Temporary Restraining Order EA-109 - Notice of Court Hearing EA-200 -Proof of Personal Service

NOTES: After the restrained party has been served, you MUST file an EA-200 Proof of Personal Service. Neither the protected person nor any other person named in these orders can serve the papers on the restrained party.

Material distributed by the Superior Court Clerk’s Office or Self-Help Center IS INTENDED FOR INFORMATIONAL AND EDUCATIONAL PURPOSES ONLY. Such material is NOT LEGAL ADVICE and is not intended to be legal advice as to your specific case. IT IS NOT INTENDED TO TAKE THE PLACE OF LEGAL ADVICE FROM AN ATTORNEY.

You are strongly urged to seek the advice of a licensed attorney before starting or completing your case in order to protect valuable legal rights that you may have, of which you may be unaware of. Please contact an attorney of your choice, the Clerk’s Office cannot give you legal advice.

Yes, I need an Interpreter!

Sí, necesito un Intérprete!

Name (Nombre): __________________________________ Case Number (Número de caso): _______________________ Language/Dialect Spoken (Que idioma/dialecto habla): □ Spanish (Español) Dialecto: _________________ □ Other: ___________ Dialect: __________________

Person requesting an Interpreter is:

Persona que solicita el intérprete es:

(Solicitante) □ Petitioner

(Demandado) □ Respondent (Persona Protegida) □ Protected Person (Persona Restringida) □ Restrained Person (Otro): ___________________________ □ Other

CLETS-001 Confidential Information for Law Enforcement

Instructions: If you are asking for a restraining order, you must complete To Court Clerk: Do not file this form. this form and give it to the court clerk, along with the other court forms The information on this form must be required in your case. If the judge grants the restraining order, information entered into the protective order you give on this form will be entered into a database (called CLETS) to help registry in CLETS. law enforcement enforce the order. If information changes later, you may complete this form again and turn it in to the court. Court fills in case number when form is received. Case Number: Information that has a star (*) next to it is required. All other information is helpful.

Date received by court:

1 Person You Want a Restraining Order Against *Name: Other names used: Marks, scars, or tattoos: SSN: Telephone: Driver s license (number and state): Vehicle type: Model: Year: Plate number: Name of employer and address:

Does the person speak English? Yes I don't know No (list language):

Does the person have any firearms (guns), firearm parts, ammunition, or body armor?

No I don't know
Yes (Give any information you have below, like the type, amount, or location of any items, if known.)

2 *Your Name:

(Skip 3 and 4 if you are asking for a gun violence restraining order (form GV-100).)

3 Your information *Age: Date of Birth (month, day, year): *Gender: M F X (nonbinary)

Race: Telephone:

Do you speak English? Yes No (list language):

4 Other People You Want Protected *Name: *Gender: Race: Date of Birth: *Name: *Gender: Race: Date of Birth: *Name: *Gender: Race: Date of Birth: *Name: *Gender: Race: Date of Birth:

Check here if you have more people to list. Write them on a separate piece of paper and write "Item 4" at the top and attach it to this form.

This is not a Court Order—Do not place in court file.

Judicial Council of California, www.courts.ca.gov Rev. January 1, 2025, Mandatory Form Confidential Information for Law Enforcement CLETS-001, Page 1 of 1 Cal. Rules of Court, rule 1.51

Can a Restraining Order to Prevent Elder or Dependent EA-100-INFO Adult Abuse Help Me?

These instructions cannot cover all of the questions that may arise in a particular case. If you do not know what to do to protect your rights, you should see a lawyer.

What is a restraining order? How much does it cost?

It is a court order that helps protect people from being There is no fee for filing a request for a restraining order. abused. You do not need to pay a fee for service of the order. A sheriff or marshal will serve the order for free. Or you may Can I get a restraining order? arrange for service by a registered process server or a If you are a person 65 years or older or a dependent adult, private party and pay any fee that is charged. you can ask for a restraining order if you have been or are The court can make the person who loses the case pay all being: the court fees and the lawyer’s fees for the other party. Physically abused Financially abused What forms do I need to get the order? Mentally or emotionally abused Neglected You must fill out all of form EA-100, Request for Elder or Abandoned or abducted Dependent Adult Abuse Restraining Orders, and form Isolated, or CLETS-001, Confidential CLETS Information. If you need Deprived by a caregiver of goods or services you attachments, you may use form MC-025, Attachment. You needed to avoid harm or suffering must also fill out items 1 and 2 on form EA-109, Notice of Court Hearing, and items 1, 2, and 3 on form EA-110, How will the order help me? Temporary Restraining Order.

The court can order a person to: Where can I get these forms? Not physically abuse, harass, hit, or threaten you Not contact or go near you, and You can get the forms from legal publishers or from the Not have any firearms (guns), firearm parts, California Courts website at www.courts.ca.gov/forms. ammunition, or body armor. This includes firearm You also may be able to find them at your local courthouse receivers and frames, and any item that may be used as or county law library or easily turned into a receiver or frame (see Penal Code section 16531). What do I need to do to get the order? For more information about the items a restrained You must go to the superior court in the county where the person cannot have, please see selfhelp.courts.ca.gov/ abuse took place or the person to be restrained lives. At the restraining-orders/prohibited-items. court, ask where you should file your request for a You can also ask for protection for people who live restraining order. (A self-help center or legal aid with you and family members. association may be able to assist you in filing your request.) At the court, give your forms to the clerk of the Who can apply for an elder or dependent court. The clerk will give you a hearing date on the Notice adult abuse restraining order? of Court Hearing form, and if your request for immediate In addition to the elder or dependent adult, the orders is granted, a copy of the Temporary Restraining following persons may apply for a restraining order on Order signed by a judicial officer. behalf of the elder or dependent adult: How soon can I get the order? A conservator or trustee of the elder or dependent adult If you ask for a temporary restraining order, the court will An attorney-in-fact of an elder or dependent adult who decide within 24 hours whether or not to make the order. acts within the authority of the power of attorney Sometimes the court decides sooner. Ask whether you A person appointed as a guardian ad litem for the elder should wait or come back later to get the signed Notice of or dependent adult Court Hearing and Temporary Restraining Order.

Any other person legally authorized to seek such relief.

Judicial Council of California Rev. January 1, 2025, Optional Form Can a Restraining Order to Prevent Elder or EA-100-INFO, Page 1 of 3 Welfare and Institutions Code, § 15657.03 Dependent Adult Abuse Help Me? (Elder or Dependent Adult Abuse Prevention)

Can a Restraining Order to Prevent Elder or Dependent EA-100-INFO Adult Abuse Help Me?

How long does the order last? Will I see the restrained person at the court hearing? If the court makes a temporary order, it will last until your hearing date. At that time, the court will decide to continue If the person comes to the hearing, yes. But that person or cancel the order. The order could last for up to five does not have the right to speak to you. If you are afraid, years. tell the court officer.

How will the person to be restrained know Can I bring someone with me to court? about the order? Yes. You can bring someone to sit with you during the Someone age 18 or older—not you or anyone else to be hearing. But that person cannot speak for you in court. protected by the order—must “serve” (give) the person to Only you or your lawyer (if you have one) can speak for be restrained a copy of the order. The server must then fill you. out form EA-200, Proof of Personal Service, and give it to you to file with the court. For help with service, ask the court clerk for form EA-200-INFO, What Is “Proof of What if I don't speak English? Personal Service?”. When you file your papers, ask the clerk if a court interpreter is available. You can also use form INT-300, What if the restrained person does not Request for Interpreter (Civil) or a local court form or obey the order? website to request an interpreter. For more information Call the police. The restrained person can be arrested and about court interpreters, go to selfhelp.courts.ca.gov/ charged with a crime. request-interpreter.

Do I have to go to court?

Yes. Go to court on the date the clerk gives you.

Do I need to bring a witness to the court hearing?

Witnesses are not required, but it helps to have more proof of the abuse than just your word. You can bring: Witnesses Written statements from witnesses made under oath Photos Medical or police reports Damaged property Threatening letters, e-mails, or telephone messages

The court may or may not let witnesses speak at the hearing. So, if possible, you should bring their written statements under oath to the hearing. (You can use Form MC-030 for this.)

Do I need a lawyer?

Having a lawyer is always a good idea, but it is not required and you are not entitled to a free, court-appointed attorney. Ask the court clerk about free and low-cost legal services and self-help centers in your county.

January 1, 2025 Can a Restraining Order to Prevent Elder or EA-100-INFO, Page 2 of 3 Dependent Adult Abuse Help Me? (Elder or Dependent Adult Abuse Prevention)

Can a Restraining Order to Prevent Elder or Dependent EA-100-INFO Adult Abuse Help Me?

What if the restrained person's abuse Can I agree with the restrained person to caused me to owe money or debts? cancel the order?

If the restrained person’s financial abuse caused you to No. Once the order is issued, only the judge can change or have certain debts or bills (such as using your name to cancel it. You or the restrained person would have to file a open a credit card and make purchases that you didn’t request with the court to cancel the order. agree to), you can ask the judge to make a special decision or finding that the restrained person caused you to have the What if I have a disability? debts or bills. This special finding may be helpful if you are sued for the debts or bills. If you have a disability and need an accommodation while you are at court, you can use form MC-410, Disability Information about the process is also Accommodation Request, to make your request. You can available online. also ask the ADA Coordinator in your court for help. For more information, see form MC-410-INFO, How to See selfhelp.courts.ca.gov/EA-restraining-order. Request a Disability Accommodation for Court.

For help in your area, contact:

[Local information may be inserted.]

Rev. January 1, 2025 Can a Restraining Order to Prevent Elder or EA-100-INFO, Page 3 of 3 Dependent Adult Abuse Help Me? (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 a Restraining Order to Prevent Elder or Dependent Adult Abuse 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.

1 Elder or Dependent Adult in Need of Protection Full Name: Gender: M F Nonbinary Age:

Fill in court name and street address:

2 Person From Whom Protection Is Sought Superior Court of California, County of Full Name: STANISLAUS 1100 I STREET Address (if known): P.O. BOX 1098 City: State: Zip: MODESTO, CA 95353

3 Person Requesting Order 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 of the person named in 1 , appointed by (name of court): Case No.: c. Other (name) (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.)

4 Contact Information 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 email.)

Address:
City: State: Zip:
Telephone: Fax:
Email Address:

This is not a Court Order.

Judicial Council of California, www.courts.ca.gov Rev. January 1, 2025, Mandatory Form Request for Elder or Dependent Adult Abuse EA-100, Page 1 of 9 Welfare and Institutions Code, § 15657.03; Restraining Orders Code of Civil Procedure, § 527.9 (Elder or Dependent Adult Abuse Prevention)

Case Number:

5 Description of Protected Person The person named in 1 (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.)

6 Additional Protected Persons a. Are you asking for protection for any other family or household members or for the conservator of the elder or dependent adult listed in 1 ? Yes No (If yes, list them): Lives with person Full Name Gender Age Relation to person in 1 ? in 1 ? 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.

7 Relationship of Parties 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.

This is not a Court Order.

Rev. January 1, 2025 Request for Elder or Dependent Adult Abuse EA-100, Page 2 of 9 Restraining Orders (Elder or Dependent Adult Abuse Prevention)

Case Number:

8 Description of Abuse 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 8b(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.
(5) Did the person in 2 use or threaten to use a gun or any other weapon?
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 8b(5)—Use of Weapons” for a title.

(6) Was the person in 1 harmed or injured as a result of the acts of abuse described above?
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 8b(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 1 the person in 2 the persons in 6 .
(Attach a copy of the order if you have one.)

This is not a Court Order.

Rev. January 1, 2025 Request for Elder or Dependent Adult Abuse EA-100, Page 3 of 9 Restraining Orders (Elder or Dependent Adult Abuse Prevention)

Case Number:

8 c. Is the person in 2 a care custodian who deprived the person in 1 of (kept from the person, did not allow the person to have or receive, or did not provide the person 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 the person): 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 8c—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 8d—Previous Abuse” for a title.

9 Venue Why are you filing in this county? (Check all that apply): a. The person in 2 lives in this county. b. The person in 1 was abused by the person in 2 in this county. c. Other (specify):

10 Other Court Cases a. Has the person in 1 or any of the persons named in 6 been involved in another court case with the person in 2 ? No Yes (If yes, specify the kind of each case and indicate where and when each was filed): 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 1 or any of the persons named in 6 and the person in 2 ? No Yes (If yes, attach a copy if you have one.)

This is not a Court Order.

Rev. January 1, 2025 Request for Elder or Dependent Adult Abuse EA-100, Page 4 of 9 Restraining Orders (Elder or Dependent Adult Abuse Prevention)

Case Number:

Check the orders you want.

11 Personal Conduct Orders I ask the court to order the person in 2 not to do any of the following things to the person in 1 or to any person 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 2 will be ordered not to take any action to get the addresses or locations of any protected person unless the court finds good cause not to make the order.

12 Stay-Away Orders 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 .
(2) The persons in 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 get to his or her home, school, or job? Yes No (If no, 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 12b—Stay-Away Orders” for a title.

This is not a Court Order.

Rev. January 1, 2025 Request for Elder or Dependent Adult Abuse EA-100, Page 5 of 9 Restraining Orders (Elder or Dependent Adult Abuse Prevention)

Case Number:

13 Move-Out Order I ask the court to order the person in 2 to move out from and not return to the residence at (address):

The person in 1 will suffer physical or emotional harm if the person in 2 does not leave the residence. The person in 2 is not named in the title or lease of the residence, either alone or with others beside the person in 1 .

I ask for this move-out order right away to last until the hearing, because:

a. The person in 2 assaulted or threatened the person in 1 ; and b. The person in 1 has the right to live at the above residence. (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 13b—My Right to Residence” for a title.

14 Order for Counseling or Anger Management Courses This item is only available in instances of alleged physical abuse or deprivation of care, not in cases with i only alleged financial abuse. a. I request the person in item 2 be ordered by the court to attend clinical counseling or anger management courses provided by a professional (a counselor, psychologist, psychiatrist, therapist, clinical social worker, or mental or behavioral health professional licensed in the state of California to provide counseling or anger management courses).

b. Explain why you are requesting an order that the person in item 2 attend clinical counseling or anger management courses. 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 14b— Counseling or Anger Management” for a title.

15 Firearms (Guns), Firearm Parts, and Ammunition Does the person in 2 own or possess any firearms (guns), firearm parts, or ammunition? This includes firearm receivers and frames, and any item that may be used as or easily turned into a receiver or frame (see Penal Code section 16531). Yes No I don’t know Unless the abuse is only financial, if the judge grants a protective order, the person in 2 will be prohibited from owning, possessing, purchasing, receiving, or attempting to purchase or receive firearms (guns), firearm parts, and ammunition while the protective order is in effect. The person in 2 will also be ordered to turn in to law enforcement, or sell to or store with a gun dealer, any firearms (guns) and firearm parts within their immediate possession or control. If an order is granted, the person in 2 will also be prohibited from owning, possessing, or buying body armor and would have to relinquish any they have.

This is not a Court Order.

Rev. January 1, 2025 Request for Elder or Dependent Adult Abuse EA-100, Page 6 of 9 Restraining Orders (Elder or Dependent Adult Abuse Prevention)

Case Number:

16 Temporary Restraining Order I request that a Temporary Restraining Order (TRO) be issued against the person in 2 to last until the hearing. I am presenting form EA-110, Temporary Restraining Order, for the court’s signature together with this Request. Has the person in 2 been told that you were going to go to court to seek a TRO against them? Yes No (If you answered no, explain why 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 16—Temporary Restraining Order” for a title.

17 Request to Give Less Than Five Days' Notice of Hearing You must have your papers personally served on the person in 2 at least five days before the hearing, unless the court orders a shorter time for service. (Read form EA-200-INFO, What Is “Proof of Personal Service”?, to learn about serving legal papers. Form EA-200, Proof of Personal Service, may be used to show the court that the papers have been served.) If you want there to be fewer than five days between service and the hearing, explain why: 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 17—Request to Give Less Than Five Days' Notice” for a title.

18 Debts Caused by Financial Abuse You can ask the judge to decide at the hearing that certain debts or bills you have were caused by the person in 2 ’s financial abuse. This may help you defend against the debt if you are sued in another case. a. If you want the judge to make this special finding, list the debts or bills you have that were caused by the person in 2 ’s financial abuse. Check here if you want to list additional debts or bills that were caused by financial abuse. You can attach form MC-025 and write “Attachment 18a—Additional Debts” for a title. Money Owed To For Amount (1) $ (2) $ (3) $ b. Describe what the person in 2 did to cause the debts and bills that you listed above. Provide as much detail as you can about the person in 2 ’s financial abuse. 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 18b—How Debt Was Incurred” for a title.

This is not a Court Order.

Rev. January 1, 2025 Request for Elder or Dependent Adult Abuse EA-100, Page 7 of 9 Restraining Orders (Elder or Dependent Adult Abuse Prevention)

Case Number:

19 Lawyer's Fees and Costs I ask the court to order payment of my lawyer’s fees court costs. The amounts requested are: Item Amount Item Amount $ $ $ $ $ $ Check here if there are more items. Put the items and amounts on the attached sheet of paper or form MC-025 and write “Attachment 19—Lawyer’s Fees and Costs” for a title.

20 Possession and Protection of Animals I ask the court to order the following: a. That the person in 1 be given the sole possession, care, and control of the animals listed below, which they own, possess, lease, keep, or hold, or which reside in their household. (Identify animals by, e.g., type, breed, name, color, sex.)

I request sole possession of the animals because (specify good cause for granting order):
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 20a—Possession of Animals” for a title.

b. That the person in 2 must stay at least yards away from, and not take, sell, transfer, encumber,
conceal, molest, attack, strike, threaten, harm, or otherwise dispose of, the animals listed above.

21 No Fee to Serve Orders If you want the sheriff or marshal to serve (notify) the person in 2 about the orders for free, ask the court clerk what you need to do.

This is not a Court Order.

Rev. January 1, 2025 Request for Elder or Dependent Adult Abuse EA-100, Page 8 of 9 Restraining Orders (Elder or Dependent Adult Abuse Prevention)

Case Number:

22 Additional Orders Requested I ask the court to make the following additional orders (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 22—Additional Orders Requested,” for a title.

23 Number of pages attached to this form, if any:

Date:

Lawyer’s name (if any) Lawyer’s signature

I declare under penalty of perjury under the laws of the State of California that the information above and on all
attachments is true and correct.

Date:

Type or print your name Signature of person filling out this request

This is not a Court Order.

Rev. January 1, 2025 Request for Elder or Dependent Adult Abuse EA-100, Page 9 of 9 Restraining Orders (Elder or Dependent Adult Abuse Prevention)

MC-025 SHORT TITLE: CASE NUMBER:

ATTACHMENT (Number) : (This Attachment may be used with any Judicial Council form.)

(If the item that this Attachment concerns is made under penalty of perjury, all statements in this Page of Attachment are made under penalty of perjury.) (Add pages as required)

Form Approved for Optional Use ATTACHMENT www.courtinfo.ca.gov Judicial Council of California MC-025 [Rev. July 1, 2009] to Judicial Council Form

Clerk stamps date here when form is filed. EA-110 Temporary Restraining Order

Person in 1 must complete items 1 , 2 and 3 only.

1 Protected Elder or Dependent Adult

a. Full Name:

Person requesting protection for the elder or dependent adult, if
different (person named in item 3 of form EA-100):
Full Name:
Lawyer for person named above (if any for this case):
Name: State Bar No.: Fill in court name and street address:
Firm Name: Superior Court of California, County of b. Your Address (If you have a lawyer, give your lawyer’s information. 1100 I STREET
If you do not have a lawyer and want to keep your home address P.O. BOX 1098
private, you may give a different mailing address instead. You do not MODESTO, CA 95353
have to give telephone, fax, or email.):

Address: Court fills in case number when form is filed.
City: State: Zip: Case Number:
Telephone: Fax:
Email Address:

2 Restrained Person (Give all the information you know. Information with a star (*) is required to add this order to the California police database. If age is unknown, give an estimate.)

*Full Name: *Age: Date of Birth:

*Race: Height: Weight: Hair Color: Eye Color:
*Gender: M F Nonbinary Home Address:
City: State: Zip:

Relationship to Protected Person:

3 Additional Protected Persons In addition to the elder or dependent adult named in 1 , the following family or household members or conservator of that person are protected by the temporary orders indicated below: Full Name Gender Age Household Member? Relation to Protected Person Yes No Yes No

Check here if there are additional protected persons. List them on an attached sheet of paper and write “Attachment 3—Additional Protected Persons” as a title. You may use form MC-025, Attachment.

4 Expiration Date This Order expires at the end of the hearing scheduled for the date and time below:

Date: Time: a.m. p.m.

This is a Court Order.

Judicial Council of California, www.courts.ca.gov Rev. January 1, 2025, Mandatory Form Temporary Restraining Order EA-110, Page 1 of 6 Code of Civil Procedure, § 527.9 Welfare and Institutions Code, § 15657.03 (CLETS–TEA or TEF) Approved by DOJ (Elder or Dependent Adult Abuse Prevention)

Case Number:

To the Person in 2 :

The court has issued the temporary orders checked as granted below. If you do not obey these orders, you can be arrested and charged with a crime. You may have to go to jail for up to one year, pay a fine of up to $1,000, or both.

5 Personal Conduct Orders Not Requested Denied Until the Hearing Granted as Follows: a. You must not do the following things to the elder or dependent adult named in 1 and to the other protected persons listed in 3 : (1) Physically abuse, financially abuse, intimidate, molest, attack, strike, stalk, threaten, assault (sexually or otherwise), hit, harass, destroy personal property of, or disturb the peace of the person. (2) 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. (3) Take any action to obtain the person’s address or location. If this item 3 is not checked, the court has found good cause not to make this order. (4) Other (specify): Other personal conduct orders are attached at the end of this Order on Attachment 5a(4).

b. Peaceful written contact through a lawyer or a process server or other person for service of legal papers related to a court case is allowed and does not violate this order. However, you may have your papers served by mail on the person in 1 .

6 Stay-Away Orders

Not Requested Denied Until the Hearing Granted as Follows:

a. You must stay at least yards away from (check all that apply):

(1) The elder or dependent adult in 1 (5) The vehicle of the person in 1
(2) Each person in 3 (6) Other (specify):
(3) The home of the elder or
dependent adult
(4) The job or workplace of the elder
or dependent adult
b. This stay-away order does not prevent you from going to or from your home or place of employment.

7 Move-Out Order

Not Requested Denied Until the Hearing Granted as Follows:
You must immediately move out from and not return to (address):

This is a Court Order.

Rev. January 1, 2025 Temporary Restraining Order (CLETS-TEA or TEF) EA-110, Page 2 of 6 (Elder or Dependent Adult Abuse Prevention)

Case Number:

8 No Firearms (Guns), Firearm Parts, or Ammunition Not Issued (financial abuse only) Granted as Follows: This order must be granted unless only financial abuse is alleged. a. You cannot own, possess, have, buy or try to buy, receive or try to receive, or in any other way get any prohibited items listed in b below.

b. Prohibited items are:
(1) Firearms (guns);
(2) Firearm parts, meaning receivers, frames, or any item that may be used as or easily turned into a receiver or
frame (see Penal Code section 16531); and
(3) Ammunition.

c. You must:
(1) Sell to or store with a licensed gun dealer, or turn in to a law enforcement agency, any firearms (guns) and
firearm parts in your immediate possession or control. This must be done within 24 hours of being served
with this Order.
(2) File a receipt with the court within 48 hours of receiving this Order that proves that your firearms (guns)
and firearm parts have been turned in, sold, or stored. (You may use form EA-800, Receipt for Firearms
and Firearm Parts, for the receipt.)

d. The court has received information that you own or possess a firearm (gun), firearm parts, or ammunition.

9 No Body Armor If the order in 8 is granted, you cannot own, possess, or buy body armor (defined in Penal Code section 16288). You must relinquish any body armor you have in your possession.

10 Financial Abuse This case does not does involve solely financial abuse unaccompanied by force, threat, harassment, intimidation, or any other form of abuse.

11 Possession and Protection of Animals

Not Requested Denied Until the Hearing Granted as Follows (specify):

a. The person in 1 is given the sole possession, care, and control of the animals listed below, which are
owned, possessed, leased, kept, or held by him or her, or reside in his or her household.
(Identify animals by, e.g., type, breed, name, color, sex.)

b. The person in 2 must stay at least yards away from, and not take, sell, transfer, encumber, conceal,
molest, attack, strike, threaten, harm, or otherwise dispose of, the animals listed above.

This is a Court Order.

Rev. January 1, 2025 Temporary Restraining Order (CLETS-TEA or TEF) EA-110, Page 3 of 6 (Elder or Dependent Adult Abuse Prevention)

Case Number:

12 Other Orders

Not Requested Denied Until the Hearing Granted as Follows (specify):

Additional orders are attached at the end of this Order on Attachment 12.

To the Person in 1 :

13 Mandatory Entry of Order Into CARPOS Through CLETS This Order must be entered into the California Restraining and Protective Order System (CARPOS) through the California Law Enforcement Telecommunications System (CLETS). (Check one): a. The clerk will enter this Order and its proof-of-service form into CARPOS. b. The clerk will transmit this Order and its proof-of-service form to a law enforcement agency to be entered into CARPOS. c. By the close of business on the date that this Order is made, the petitioner or the petitioner's lawyer should deliver a copy of the Order and its proof-of-service form to the law enforcement agencies listed below to enter into CARPOS:

Name of Law Enforcement Agency Address (City, State, Zip)

Additional law enforcement agencies are listed at the end of this Order on Attachment 13.

14 No Fee to Serve (Notify) Restrained Person If the sheriff or marshal serves this Order, he or she will do it for free.

15 Number of pages attached to this Order, if any:

Date: Judicial Officer

This is a Court Order.

Rev. January 1, 2025 Temporary Restraining Order (CLETS-TEA or TEF) EA-110, Page 4 of 6 (Elder or Dependent Adult Abuse Prevention)

Case Number:

Warnings and Notices to the Restrained Person in 2

You Cannot Have Firearms (Guns), Firearm Parts, or Ammunition

If the court grants the orders in item 8 , you cannot own, have, possess, buy or try to buy, receive or try to receive, or otherwise get any prohibited items listed in item 8b on page 3 while this Order is in effect. If you do, you can go to jail and pay a $1,000 fine. You must sell to or store with a licensed gun dealer, or turn in to a law enforcement agency, any firearms (guns) and firearm parts that you have or control as stated in item 8 . The court will require you to prove that you did so. Notice Regarding Nonappearance at Hearing and Service of Order

If you have been personally served with this Temporary Restraining Order and form EA-109, Notice of Court Hearing, but you do not appear at the hearing either in person or by a lawyer, and a restraining order that does not differ from this order except for the expiration date is issued at the hearing, a copy of the order will be served on you by mail at the address in item 2 .

If this address is not correct or you wish to verify that the Temporary Restraining Order was converted into a restraining order at the hearing without substantive change, or to find out the duration of the order, contact the clerk of the court.

After You Have Been Served With a Restraining Order

Obey all the orders. Read form EA-120-INFO, How Can I Respond to a Request for Elder or Dependent Adult Abuse Retraining Orders?, to learn how to respond to this Order.

If you want to respond, fill out form EA-120, Response to Request for Elder or Dependent Adult Abuse Restraining

Orders, and file it with the court clerk. You do not have to pay any fee to file your response.

You must have form EA-120 served on the person in 1 (the person asking the court for protection of the elder or dependent adult or the elder or dependent adult if no other person is named in that item), or that person’s attorney, by mail. You cannot do this yourself. The person who does the mailing should complete and sign form EA-250, Proof of Service of Response by Mail. File the completed proof of service with the court clerk before the hearing date or bring it with you to the hearing.

In addition to the response, you may file and have declarations served signed by you and other persons who have personal knowledge of the facts. You may use form MC-030, Declaration, for this purpose. It is available from the clerk’s office at the court shown on page 1 of this form or at www.courts.ca.gov/forms. If you do not know how to prepare a declaration, you should see a lawyer.

Whether or not you file a response, you should attend the hearing. If you have any witnesses, they must also go to the hearing.

At the hearing, the judge can make restraining orders against you that last for up to five years. Tell the judge why you disagree with the orders requested.

Instructions for Law Enforcement

Enforcing the Restraining Order This order is enforceable by any law enforcement agency that has received the order, is shown a copy of the order, or has verified its existence on the California Restraining and Protective Orders System (CARPOS). If the law enforcement agency has not received proof of service on the restrained person, the agency must advise the restrained person of the terms of the order and then must enforce it. Violations of this order are subject to criminal penalties.

This is a Court Order.

Rev. January 1, 2025 Temporary Restraining Order (CLETS-TEA or TEF) EA-110, Page 5 of 6 (Elder or Dependent Adult Abuse Prevention)

Case Number:

Start Date and End Date of Orders This order starts on the date next to the judge’s signature on page 4. The order ends on the expiration date in item 4 on page 1.

Arrest Required If Order Is Violated If an officer has probable cause to believe that the restrained person had notice of the order and has disobeyed the order, the officer must arrest the restrained person. (Pen. Code, §§ 836(c)(1), 13701(b).) A violation of the order may be a violation of Penal Code section 166 or 273.6. Agencies are encouraged to enter violation messages into CARPOS.

Notice/Proof of Service The law enforcement agency must first determine if the restrained person had notice of the order. Consider the restrained person “served” (given notice) if (Pen. Code, § 836(c)(2)):

The officer sees a copy of the proof of service or confirms that the proof of service is on file; or The restrained person was informed of the order by an officer. An officer can obtain information about the contents of the order and proof of service in CARPOS. If proof of service on the restrained person cannot be verified, the agency must advise the restrained person of the terms of the order and then enforce it.

If the Protected Person Contacts the Restrained Person Even if the protected person invites or consents to contact with the restrained person, this order remains in effect and must be enforced. The protected person cannot be arrested for inviting or consenting to contact with the restrained person. The order can be changed only by another court order. (Pen. Code, § 13710(b).)

Conflicting Orders—Priorities of Enforcement If more than one restraining order has been issued protecting the protected person from the restrained person, the orders must be enforced in the following priority (see Pen. Code, § 136.2 and Fam. Code, §§ 6383(h)(2), 6405(b)):

1. Emergency Protective Order (EPO): If one of the orders is an Emergency Protective Order (form EPO-001), provisions (e.g., stay-away order) that are more restrictive than in the other restraining/protective orders must be enforced. Provisions of another order that do not conflict with the EPO must be enforced.

2. No-Contact Order: If a restraining/protective order includes a no-contact order, the no-contact order must be enforced. Item 5a(2) is an example of a no-contact order.

3. Criminal Protective Order (CPO): If none of the orders include an EPO or a no-contact order, the most recent CPO must be enforced. (Fam. Code, §§ 6383(h)(2) and 6405(b).) Additionally, a CPO issued in a criminal case involving charges of domestic violence, Penal Code sections 261, 261.5, or former 262, or charges requiring sex offender registration must be enforced over any civil court order. (Pen. Code, § 136.2(e)(2).) All provisions in the civil court order that do not conflict with the CPO must be enforced.

4. Civil Restraining Orders: If there is more than one civil restraining order (e.g., domestic violence, juvenile, elder abuse, civil harassment), then the order that was issued last must be enforced. Provisions that do not conflict with the most recent civil restraining order must be enforced.

   (Clerk will fill out this part.)

   —Clerk's Certificate—

Clerk’s Certificate I certify that this Temporary Restraining Order is a true and correct copy of the [seal] original on file in the court.

Date: Clerk, by , Deputy

This is a Court Order.

Rev. January 1, 2025 Temporary Restraining Order (CLETS-TEA or TEF) EA-110, Page 6 of 6 (Elder or Dependent Adult Abuse Prevention)

EA-109 Notice of Court Hearing Clerk stamps date here when form is filed.

1 Elder or Dependent Adult in Need of Protection

a. Full Name:
Person requesting protection for the elder or dependent adult, if
different (person named in item 3 of form EA-100):

Full Name:

Lawyer for person named above (if any for this case):
Name: State Bar No.: Fill in court name and street address:
Firm Name: Superior Court of California, County of b. Address for person named above (If you have a lawyer, give your 1100 I STREET
lawyer's information. If you do not have a lawyer, give information P.O. BOX 1098
for the person requesting the order. If you want to keep your home MODESTO, CA 95353
address private, you may give a different mailing address instead.
You do not have to give telephone, fax, or email.): Court fills in case number when form is filed.
Address: Case Number:
City: State: Zip:

Telephone: Fax:

Email Address:

2 Person You Want Protection From

Full Name: The court will complete the rest of this form.

3 Notice of Hearing A court hearing is scheduled on the request for restraining orders against the person in 2 :

Name and address of court if different from above:
Hearing Date: Time:
Date
Dept.: Room:

To the person in 2 : If you attend the hearing (in person, by phone, or by videoconference) and the judge grants a restraining order against you, the order will be effective immediately, and you could be arrested if you violate the order. If you do not attend the hearing, the judge may still grant the restraining order that could last up to five years. After you receive a copy of the order, you could be arrested if you violate the order.

4 Temporary Restraining Orders (Any orders granted are on Form EA-110, served with this notice.) a. Temporary Restraining Orders for personal conduct and stay-away orders as requested in form EA-100, Request for Elder or Dependent Adult Abuse Restraining Orders are (check only one box below): (1) All GRANTED until the court hearing. (2) All DENIED until the court hearing. (Specify reasons for denial in b, below.) (3) Partly GRANTED and partly DENIED until the court hearing. (Specify reasons for denial in b, below.)

Judicial Council of California, www.courts.ca.gov Rev. January 1, 2025, Mandatory Form Notice of Court Hearing EA-109, Page 1 of 3 Welfare and Institutions Code, § 15657.03 (Elder or Dependent Adult Abuse Prevention) Approved by DOJ

Case Number:

4 Temporary Restraining Orders (Continued)

b. Reasons for denial of some or all of those personal conduct and stay-away orders as requested in form EA-100, Request for Elder or Dependent Adult Abuse Restraining Orders, are:

(1) The facts as stated in form EA-100 do not sufficiently show reasonable proof of a past act or
acts of abuse of the elder or dependent adult by the person in 2 .

(2) Other (specify): As stated on Attachment 4b.

5 Service of Documents by the Person in 1

At least five days before the hearing, someone age 18 or older—not you or anyone to be protected—must personally give (serve) a court file-stamped copy of this form EA-109, Notice of Court Hearing, to the person in 2 along with a copy of all the forms indicated below: a. EA-100, Request for Elder or Dependent Adult Abuse Restraining Orders (file-stamped) b. EA-110, Temporary Restraining Order (file-stamped) IF GRANTED c. EA-120, Response to Request for Elder or Dependent Adult Abuse Restraining Orders (blank form) d. EA-120-INFO, How Can I Respond to a Request for Elder or Dependent Adult Abuse Restraining Orders? e. Other (specify):

Date: Judicial Officer

To the Person in 1 :

The court cannot make the restraining orders after the court hearing unless the person in 2 has been personally given (served) a copy of your request and any temporary orders. To show that the person in 2 has been served, the person who served the forms must fill out a proof of service form. Form EA-200, Proof of Personal Service, may be used. For information about service, read form EA-200-INFO, What Is “Proof of Personal Service”? You may ask to reschedule the hearing if you are unable to find the person in 2 and need more time to serve the documents, or for other good reasons. Read form EA-115-INFO, How to Ask for a New Hearing Date. You must attend the hearing if you want the judge to make any of the orders you requested on form EA-100, Request for Elder or Dependent Adult Abuse Restraining Orders. Bring any evidence or witnesses you have. For more information, read form EA-100-INFO, Can a Restraining Order to Prevent Elder or Dependent Adult Abuse Help Me?

Rev. January 1, 2025 Notice of Court Hearing EA-109, Page 2 of 3 (Elder or Dependent Adult Abuse Prevention)

Case Number:

To the Person in 2 :

If you want to respond to the request for orders in writing, file form EA-120, Response to Request for Elder or

Dependent Adult Abuse Restraining Orders, and have someone age 18 or older—not you or anyone to be protected— mail it to the person in 1 .

The person who mailed the form must fill out a proof of service form. Form EA-250, Proof of Service of Response by Mail, may be used. File the completed form with the court before the hearing and bring a copy with you to the court hearing.

Whether or not you respond in writing, go to the hearing if you want the judge to hear from you before making an order. You may tell the judge why you agree or disagree with the orders requested.

You may bring witnesses and other evidence.

At the hearing, the judge may make restraining orders against you that could last up to five years and may order you to sell or turn in any firearms (guns) and firearm parts that you own or possess. This includes firearm receivers and frames, and any item that may be used as or easily turned into a receiver or frame (see Penal Code section 16531). If an order is granted, you will also be prohibited from owning, possessing, or buying body armor and will have to relinquish any body armor you have.

If you are unable to attend your court hearing or need more time to prepare your case, you may ask to reschedule your

court date. Read form EA-115-INFO, How to Ask for a New Hearing Date.

Request for Accommodations

Assistive listening systems, computer-assisted real-time captioning, or sign language
interpreter services are available if you ask at least five days before the hearing. Contact the
clerk's office or go to www.courts.ca.gov/forms for Disability Accommodation Request
(form MC-410). (Civ. Code, § 54.8.)

(Clerk will fill out this part.)

—Clerk’s Certificate—

I certify that this Notice of Court Hearing is a true and correct copy of the original on file in the court.

Clerk’s Certificate
[seal]

Date: Clerk, by , Deputy

Rev. January 1, 2025 Notice of Court Hearing EA-109, Page 3 of 3 (Elder or Dependent Adult Abuse Prevention)

EA-200-INFO What Is “Proof of Personal Service”?

What is “Service”?

Service is the act of giving your legal papers to the other party. There are many kinds of service—in person, by mail, and others. This form is about personal or “in-person service.” The following types of restraining order forms must be served “in person”: Request for Elder or Dependent Adult Abuse Restraining Orders (form EA-100), the Notice of Court Hearing (form EA-109), Temporary Restraining Order (form EA-110), Request for Elder or Dependent Adult Restraining Order Allowing Contact (form EA-300), and Notice of Court Hearing to Allow Contact (form EA-309). That means that someone must personally “serve” (give) a copy of the forms to the person to be restrained. These forms cannot be served by mail.

Service lets the other person know: What orders you are asking for The hearing date How to respond

Why do I have to get the orders served?

The police cannot arrest anyone for violating an order unless that person knows about the order. The judge cannot make the orders permanent unless the restrained person was served.

Who can serve?

Ask someone you know, a process server, or a law enforcement agency to
personally serve (give) a copy of the forms to the person to be restrained. You
cannot send the forms to that person by mail. The server must:

Be 18 years of age or older
Not be you or anyone whom you are asking to be protected by the orders. The
sheriff or marshal may be authorized to serve the court’s orders for free. A
“registered process server” is a business you pay to deliver court forms. Look for
“Process Serving” in the Yellow Pages or on the Internet. (If a law enforcement
agency or the process server uses a different proof of service form, make sure it
Don't serve it by mail! lists the forms served.)

How to serve Ask the server to:

Walk up to the person to be served. Make sure it is the right person. Ask the person’s name. Give the person copies of all papers checked on Form EA-200, Proof of Personal Service. Fill out and sign the Proof of Personal Service form. Give the signed Proof of Personal Service to you.

What if the person won’t take the papers or tears them up?

If the person won’t take the papers, just leave them near him or her. It doesn’t matter if the person tears them up. Service is still complete.

Judicial Council of California www.courts.ca.gov EA-200-INFO, Page 1 of 2 Rev. January 1, 2023, Optional Form What Is “Proof of Personal Service”? (Elder or Dependent Adult Abuse Prevention)

EA-200-INFO What Is “Proof of Personal Service”?

When do the orders have to be served? It depends. To know the exact date, you have to look at two things on form EA-109, Notice of Court Hearing or form EA-309, Notice of Court Hearing to Allow Contact :

First, look at the hearing date on form EA-109 Next, look at the number of days in item 5 on page 2 of (item 3 on page 1) or form EA-309 (item 5 on form EA-109 or in item 6 on page 2 of form EA-309. page 2).

Look at a calendar. Subtract the number of days in 5 on form EA-109 or the number of days in item 6 on form EA-309 from the hearing date. That is the final date to have the orders served. It is always OK to serve earlier than that date. If nothing is checked or written in 5 on form EA-109 or 6 on form EA-309, you must serve the orders at least five days before the hearing.

Who signs the Proof of Personal Service? Only the person who serves the forms can sign form EA-200, Proof of Personal Service. You do not sign it; the restrained person does not need to sign it.

What do I do with the completed Proof of Personal Service? If someone other than the sheriff serves the papers, you should: Make several copies. File the original with the court before your hearing. Bring a copy of the completed Proof of Personal Service to your hearing. Ask the clerk to enter the Proof of Service (unless for form EA-300) into the California Law Enforcement Telecommunications System (CLETS), a special computer system that lets police all over the state find out about the orders protecting you. If the clerk tells you that the court cannot enter it into the computer, take a copy of the Temporary Restraining Order (form EA-110) and Proof of Personal Service (form EA-200) to your local police. They will put the information into the state computer system. That way, police all over the state will know that your restraining order has been served. If the sheriff serves the papers, he or she will send the proof of service to the court and CLETS for you. Always keep an extra copy of the restraining orders with you for your safety. Note: Restraining orders to allow contact (which use the EA-300 form series) are not entered into CLETS.

What happens if I can’t get the orders served before the hearing date?

Before your hearing, fill out and file form EA-115, Request to Continue Court Hearing and to Reissue Temporary Restraining Order (or form EA-315, if you are trying to serve forms EA-300 or EA-309). This form asks the court for a new hearing date and makes your orders last until then. Ask the clerk for the form. After the court has reissued the orders, attach a copy of form EA-116, Notice of New Hearing Date and Order on Issuance, (or form EA-316) to a copy of your original orders. Ask the clerk to enter form EA-116 into CLETS, or the clerk may ask you or your attorney to deliver a copy to the police. That way, the police will know your orders are still in effect.

Rev. January 1, 2023 EA-200-INFO, Page 2 of 2 What Is “Proof of Personal Service”? (Elder or Dependent Adult Abuse Prevention)

EA-200 Proof of Personal Service Clerk stamps date here when form is filed.

1 Elder or Dependent Adult Name:

2 Person From Whom Protection Is Sought or Person Alleged to Be Preventing Contact Name:

3 Notice to Server The server must: Fill in court name and street address: Be 18 years of age or older. Superior Court of California, County of STANISLAUS Not be listed in items 1 , 3 , or 6 1100 I STREET of form EA-100 or be listed in P.O. BOX 1098 items 1 , 2 , 3 , or 4 on form EA-300. Give a copy of all documents checked in 4 to the person in 2 . (You cannot send them by mail.) Then complete and sign this Court fills in case number when form is filed. form and give or mail it to the person in 1 . Case Number:

PROOF OF PERSONAL SERVICE

4 I gave the person in 2 a copy of the forms checked below: a. EA-109, Notice of Court Hearing b. EA-110, Temporary Restraining Order c. EA-100, Request for Elder or Dependent Adult Abuse Restraining Orders d. EA-120, Response to Request for Elder or Dependent Adult Abuse Restraining Orders (blank form) e. EA-120-INFO, How Can I Respond to a Request for Elder or Dependent Adult Abuse Restraining Orders? f. EA-130, Elder or Dependent Adult Abuse Restraining Order After Hearing g. EA-250, Proof of Service of Response by Mail (blank form) h. EA-800, Receipt for Firearms, Firearm Parts, and Ammunition (blank form) i. EA-300, Request for Elder or Dependent Adult Restraining Order Allowing Contact j. EA-309, Notice of Court Hearing to Allow Contact k. EA-320, Response to Request for Elder or Dependent Adult Restraining Order Allowing Contact (blank form) l. EA-320-INFO, How Can I Respond to a Request for an Elder or Dependent Adult Restraining Order Allowing Contact? m. EA-330, Elder or Dependent Adult Restraining Order Allowing Contact After Hearing n. Other (specify):

5 I personally gave copies of the documents checked above to the person in 2 : a. On (date): b. At (time): a.m. p.m. c. At this address: City: State: Zip:

Judicial Council of California, www.courts.ca.gov Rev. January 1, 2023, Optional Form Proof of Personal Service EA-200, Page 1 of 2 Welfare and Institutions Code, § 15657.03 (Elder or Dependent Adult Abuse Prevention)

Case Number:

6 Server's Information Name: Address: City: State: Zip: Telephone: (If you are a registered process server): County of registration: Registration number:

I declare under penalty of perjury under the laws of the State of California that the information above is true and
correct.
Date:

Type or print server's name Server to sign here

Rev. January 1, 2023 Proof of Personal Service EA-200, Page 2 of 2 (Elder or Dependent Adult Abuse Prevention)

These Forms Are To Be Served On the Respondent BLANK, After You Receive Your Notice of Hearing and Temporary Restraining Order back from the Judge

INSTRUCTIONS FOR THE RESPONDENT: A. If you are served with a NoticeofCourtHearingandTemporaryRestrainingOrder(ElderorDependent AdultAbuse)(form EA-110) and a RequestforOrderstoStopElderorDependentAdultAbuse(form EA-100), you should promptly seek legal advice. If you have no attorney, the attorney referral service of your local bar association may be of assistance.

B. If you wish to respond to or oppose the request for orders, you should file a ResponsetoRequestfor OrderstoStopElderorDependentAdultAbuse(form EA-120). An original response must be filed with the Court and a copy served on the petitioner (person asking for protection) or the petitioner’s attorney. You do not have to pay any fee to file your response.

In addition to the response, you may file and serve declarations signed by you and other persons who have personal knowledge of the facts. A declaration form (form MC-030) is available from the Court Clerk's Office. If you do not know how to prepare a declaration, you should see an attorney. After you have filed the response with the Clerk of the Court, a copy must be delivered personally or by mail to the petitioner or the petitioner's attorney.

You cannot serve the paperwork yourself. The person who serves the petitioner must complete and sign a ProofofPersonalService(form EA-200) (for personal service) or ProofofServicebyMail(form EA-250) (for service by mail). You should file the completed form with the Court Clerk before the hearing date or bring it with you to the hearing.

If the Court orders you to relinquish firearms, you must sell all your firearms to a licensed gun dealer or relinquish them to a law enforcement agency. You must file a receipt showing that you have sold or relinquished the firearms within 72 hours of receiving the order. You may use ProofofFirearmsTurnedInor Sold(form EA-800) for this purpose.

C. If you wish to oppose the request for orders, in addition to filing a response you should be present at the hearing. If you have any witnesses, they must also be present at the hearing.

Judicial Council forms, local forms and information are available in the Superior Court Clerk’s Office, the Stanislaus County Law Library located at 1101 13th Street, Modesto, and on the following Websites:

Stanislaus County Superior Court

• http://www.stanct.org

Judicial Council’s Self-Help website

• http://www.courtinfo.ca.gov/selfhelp

For more information on Libraries, Websites, or Self-Help Legal Books • http://www.courtinfo.ca.gov/selfhelp/lowcost/libraries.html California Superior Court’s Interactive Electronic Forms Program

How Can I Respond to a Request for Elder or EA-120-INFO Dependent Adult Abuse Restraining Orders?

What is an elder or dependent adult abuse What if I don't agree with what the order restraining order? says? It is a court order that prohibits you from doing certain You still must obey the order until the hearing. If you things and going certain places. disagree with the orders the person is asking for, fill out form EA-120, Response to Request for Elder and What does the order do? Dependent Adult Abuse Restraining Orders, before your The court can order you to: hearing date and file it with the court. If you need to Not contact the person who is protected by the order include attachments, you can use form MC-025. You can Stay away from that person and the person’s home and get the forms from legal publishers or from the California workplace Courts website at www.courts.ca.gov/forms. You also may Move out of the place where you and that person be able to find them at your local courthouse or county law are living together library. Not have any firearms (guns), firearm parts, ammunition, or body armor as long as the order is in Do I have to serve the other person with a effect. This includes firearm receivers and frames, and copy of my response? any item that may be used as or easily turned into a Yes. Have someone age 18 or older—not you—mail a receiver or frame (see Penal Code section 16531). copy of completed Form EA-120 to the person who asked For more information about the items you would not be for the order (or that person’s lawyer). (This is called allowed to have, please see selfhelp.courts.ca.gov/ “service by mail.”) restraining-orders/prohibited-items. The person who serves the form by mail must fill out form EA-250, Proof of Service of Response by Mail. Have theWho can ask for a restraining order? person who did the mailing sign the original. Take the A person who is being: completed form back to the court clerk or bring it with you Financially abused Deprived by a caregiver to the hearing. Abandoned or abducted of goods or services Harmed necessary to live on Do I need a lawyer? Neglected Having a lawyer is always a good idea, but it is not Isolated required, and you are not entitled to a free, court-appointed A conservator may seek an order on behalf of an elder or attorney. Ask the court clerk about free and low-cost legal dependent adult. services and self-help centers in your county.

I've been served with a request for elder or What if I don't speak English? dependent adult abuse restraining orders. What do I do now? When you file your papers, ask the clerk if a court Read the papers served on you very carefully. The Notice interpreter is available. You can also use form INT-300, of Court Hearing tells you when to appear in court. There Request for Interpreter (Civil) or a local court form or may also be a Temporary Restraining Order forbidding website to request an interpreter. For more information you from doing certain things. You must obey the order about court interpreters, go to selfhelp.courts.ca.gov/ until the hearing. request-interpreter.

What if I don't obey the order? The police can arrest you. You can go to jail and pay a fine.

Judicial Council of California, www.courts.ca.gov Rev. January 1, 2025, Optional Form How Can I Respond to a Request for Elder or EA-120-INFO, Page 1 of 2 Welfare and Institutions Code, § 15657.03 Dependent Adult Abuse Restraining Orders? (Elder or Dependent Adult Abuse Prevention)

How Can I Respond to a Request for Elder or EA-120-INFO Dependent Adult Abuse Restraining Orders?

Should I go to the court hearing? How long does the order last?

Yes. You should go to court on the date listed on form If the court issued a temporary restraining order before the EA-109, Notice of Court Hearing. If you do not go to the hearing, it will last until your hearing date. At that time, the hearing, the judge can make orders against you without court will decide to continue or cancel the order. Any order hearing from you. issued at the hearing can last for up to five years.

What if I have a gun?

If a restraining order is issued, unless the order is to

prevent financial abuse only, you cannot own, possess, or

have a firearm (gun), firearm parts, ammunition, or body armor while the order is in effect. If you have a firearm (gun) or firearm parts in your immediate possession or control, you must sell it to or store it with a licensed gun dealer or turn it in to a law enforcement agency.

Can I agree with the protected person to cancel the order?

No. Once the order is issued, only the judge can change or cancel it. You or the protected person would have to file a request with the court to cancel the order.

What if I have a disability?

If you have a disability and need an accommodation while

you are at court, you can use form MC-410, Disability Accommodation Request, to make your request. You can also ask the ADA Coordinator in your court for help. For

more information, see form MC-410-INFO, How to Request a Disability Accommodation for Court.

Information about the process is also available online.

Will I see the person who asked for the See selfhelp.courts.ca.gov/EA-restraining-order.order at the court hearing?

Yes. Assume that the person who is asking for the order For help in your area, contact: will attend the hearing. Do not talk to him or her unless the judge or that person’s attorney says that you can. [Local information may be inserted.]

Can I bring a witness to the court hearing?

Yes. You can bring witnesses or documents that support your case to the hearing. But if possible, you should also bring the witnesses’ written statements of what they saw or heard. Their statements must be made under penalty of perjury. You can use form MC-030 for this.

Rev. January 1, 2025 How Can I Respond to a Request for Elder or EA-120-INFO, Page 2 of 2 Dependent Adult Abuse Restraining Orders? (Elder or Dependent Adult Abuse Prevention)

Response to Request for Elder or Clerk stamps date here when form is filed. EA-120 Dependent Adult Abuse Restraining Orders

Use this form to respond to the Request (form EA-100) Read How Can I Respond to a Request for Elder or Dependent Adult Abuse Restraining Orders? (form EA-120-INFO) to protect your rights. Fill out this form and take it to the court clerk. Have someone age 18 or older—not you—serve the person requesting protection in 1 by mail with a copy of this form and any attached pages. (Use form EA-250, Proof of Service of Response by Mail.) Fill in court name and street address: 1 Elder or Dependent Adult Seeking Protection Superior Court of California, County of STANISLAUS Name: 1100 I STREET Name of person asking for the protection, if different (This is the P.O. BOX 1098 MODESTO, CA 95353 person named in item 3 of the request (form EA-100).)

2 Person From Whom Protection Is Sought Court fills in case number when form is filed. a. Your Name: Case Number: 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 Present your response and any opposition at the
your home address private, you may give a different mailing hearing. Write your hearing date, time, and place address instead. You do not have to give telephone, fax, or
email.) from form EA-109, item 3 , here:
Address: Hearing Date: Time:
City: State: Zip: Date Dept.: Room:
Telephone: Fax:
If you were served with a Temporary Email Address:
Restraining Order, you must obey it until the
hearing. At the hearing, the court may make

3 Personal Conduct Orders orders against you that last for up to five years. a. I agree to the orders requested. b. I do not agree to the orders requested. (Specify why you disagree in item 15 on page 4.) c. I agree to the following orders (specify below or in item 15 on page 4):

4 Stay-Away Orders a. I agree to the orders requested. b. I do not agree to the orders requested. (Specify why you disagree in item 15 on page 4.) c. I agree to the following orders (specify below or in item 15 on page 4):

Judicial Council of California, www.courts.ca.gov Rev. January 1, 2025, Mandatory Form Response to Request for Elder EA-120, Page 1 of 5 Welfare and Institutions Code, § 15657.03 or Dependent Adult Abuse Restraining Orders (Elder or Dependent Adult Abuse Prevention)

Case Number:

5 Move-Out Orders a. I agree to the orders requested. b. I do not agree to the orders requested. (Specify why you disagree in item 15 on page 4.) c. I agree to the following orders (specify below or in item 15 on page 4):

6 Additional Protected Persons a. I agree that the persons listed in item 6 of form EA-100 may be protected by the order requested. b. I do not agree that the persons listed in item 6 of form EA-100 may be protected by the order requested.

7 Order for Counseling or Anger Management Courses This item is only available in instances of alleged physical abuse or deprivation of care, not in cases with i only alleged financial abuse. a. I agree to the orders requested. b. I do not agree to the orders requested. (Specify why you disagree in item 15 on page 4.) c. I agree to the following orders (specify below or in item 15 on page 4):

8 Firearms (Guns), Firearm Parts, and Ammunition If you were served with form EA-110, Temporary Restraining Order, you cannot own or possess any firearms (guns), firearm parts, or ammunition. This includes firearm receivers and frames, and any item that may be used as or easily turned into a receiver or frame (see Penal Code section 16531). (See item 8 of form EA-110.) You must sell to or store with a licensed gun dealer, or turn in to a law enforcement agency, any firearms (guns) or firearm parts in your immediate possession or control within 24 hours of being served with form EA-110. You must file a receipt with the court. You may use form EA-800, Receipt for Firearms and Firearm Parts, for the receipt.

a. I do not own or control any firearms (guns), firearm parts, or ammunition.
b. I ask for an exemption from the firearms prohibition under Code of Civil Procedure section 527.9(f) because
carrying a firearm is a condition of my employment, and my employer is unable to reassign me to another
position where a firearm is unnecessary. (Explain):
Check here if there is not enough space below for your answer. Put your complete answer on an attached
sheet of paper and write "Attachment 8b—Firearms Surrender Exemption" as a title. You may use form
MC-025, Attachment.

c. I have turned in my firearms (guns) and firearm parts to the police or sold them to or stored them with a
licensed gun dealer.

A copy of the receipt is attached. has already been filed with the court.

Rev. January 1, 2025 Response to Request for Elder EA-120, Page 2 of 5 or Dependent Adult Abuse Restraining Orders (Elder or Dependent Adult Abuse Prevention)

Case Number:

9 No Body Armor

If you were served with form EA-110, Temporary Restraining Order, you are prohibited from owning, possessing,
or buying body armor. You must also relinquish any body armor you have in your possession.

(Check all that apply):
a. I do not own or have any body armor.
b. I have relinquished all body armor that I have in my possession.
c. I was granted an exception, or will ask for an exception, to have body armor. Note: This exception is granted
by a chief of police or sheriff. See Penal Code section 31360(c). (Attach a copy of the letter granting
permission, if you have one.)

10 Debts Caused by Financial Abuse a. I agree to the findings requested. b. I do not agree to the findings requested. (Specify why you disagree in item 15 on page 4.) c. I agree to the following findings (specify below or in item 15 on page 4):

11 Possession and Protection of Animals a. I agree to the orders requested. b. I do not agree to the orders requested. (Specify why you disagree in item 15 on page 4.) c. I agree to the following orders (specify below or in item 15 on page 4):

12 Other Orders a. I agree to the orders requested. b. I do not agree to the orders requested. (Specify why you disagree in item 15 on page 4.) c. I agree to the following orders (specify below or in item 15 on page 4):

13 Denial I did not do anything described in item 8 of form EA-100. (Skip to 15 .)

Rev. January 1, 2025 Response to Request for Elder EA-120, Page 3 of 5 or Dependent Adult Abuse Restraining Orders (Elder or Dependent Adult Abuse Prevention)

Case Number:

14 Justification or Excuse If I did some or all of the things that the person in 1 has accused me of, my actions were justified or excused for the following reasons (explain): Check here if there is not enough space below for your answer. Put your complete answer on an attached sheet of paper and write "Attachment 14—Justification or Excuse" as a title. You may use form MC-025, Attachment.

15 Reasons I Do Not Agree to the Requests Explain your answers to each order or finding requested that you do not agree with.

Check here if there is not enough space below for your answer. Put your complete answer on an attached sheet of paper and write "Attachment 15-Reasons I Disagree" as a title. You may use form MC-025, Attachment.

Rev. January 1, 2025 Response to Request for Elder EA-120, Page 4 of 5 or Dependent Adult Abuse Restraining Orders (Elder or Dependent Adult Abuse Prevention)

Case Number:

16 Lawyer's Fees and Costs a. I ask the court to order payment of my lawyer’s fees court costs. The amounts requested are:

Item Amount Item Amount
$ $
$ $
$ $

Check here if there are more items. Put the items and amounts on the attached sheet of paper and write
“Attachment 16—Lawyer’s Fees and Costs” for a title. You may use form MC-025, Attachment.

b. I ask the court to deny the request of the person asking for protection named in 1 that I pay his or her
lawyer’s fees and costs.

17 Number of pages attached to this form, if any:

Date:

Lawyer’s name (if any) Lawyer’s signature

I declare under penalty of perjury under the laws of the State of California that the information above and on
all attachments is true and correct.

Date:

Type or print your name Sign your name

Rev. January 1, 2025 Response to Request for Elder EA-120, Page 5 of 5 or Dependent Adult Abuse Restraining Orders (Elder or Dependent Adult Abuse Prevention)

Proof of Service of Clerk stamps date here when form is filed. EA-250 Response by Mail

1 Elder or Dependent Adult Seeking Protection Full Name:

2 Person From Whom Protection Is Sought Your Full Name:

3 Notice to Server The server must: Be 18 years of age or older. Fill in court name and street address: Superior Court of California, County of Live or be employed in the county where the mailing took place. 1100 I STREET Not be listed in items 1 , 3 , or 6 P.O. BOX 1098 of form EA-100 or in items 1 , 2 , 3 or 4 on form EA-300. Mail a copy of all documents checked Court fills in case number when form is filed. in 4 to the person in 1 . Case Number: Complete and sign this form and give it to the person in 2 .

4 PROOF OF SERVICE BY MAIL I am 18 years of age or older and not a party to this proceeding. I live or am employed in the county where the mailing took place. I mailed the person in 1 a copy of all documents checked below: a. Form EA-120, Response to Request for Elder or Dependent Adult Abuse Restraining Orders (completed) b. Form EA-320, Response to Request for Elder or Dependent Adult Restraining Order Allowing Contact c. Other (specify):

5 I placed copies of the documents above in a sealed envelope and mailed them as described below: a. Mailed to (name): b. To this address: City: State: Zip: c. On (date): Mailed from (city): State:

6 Server's Information Name: Telephone: Address: City: State: Zip: (If you are a registered process server): County of registration: Registration number: I declare under penalty of perjury under the laws of the State of California that the information above is true and correct.

Date: Server to sign here

Type or print server's name

Judicial Council of California, www.courts.ca.gov Rev. January 1, 2023, Optional Form Proof of Service of Response by Mail EA-250, Page 1 of 1 Welfare and Institutions Code, § 15657.03 (Elder or Dependent Adult Abuse Prevention)

How Do I Turn In, Sell, or Store My Firearms EA-800-INFO and Firearm Parts?

What items do I need to turn in, sell, or store? How do I turn in the prohibited items to law enforcement?You must turn in, sell, or store all of the following Call your local law enforcement agency to ask about theirprohibited items that you have or control: procedures. Unload your firearms and take a copy of the Firearms, including any handgun, rifle, shotgun, court order with you. and assault weapon; and Do not bring firearms to court. Firearm parts, meaning receivers, frames, or any item that may be used as or easily turned into a If I turn in the prohibited items to law receiver or frame (see Penal Code section 16531). enforcement, how long will they keep them? These may also be called "ghost guns." It depends. There are procedures for getting your firearms back after the restraining order has expired. Ask the lawYou also may not have or possess ammunition. enforcement agency for more information. How do I properly turn in, sell, or store the prohibited items? After I turn in the prohibited items to law enforcement, can I change my mind?You must take them to: Yes. You are allowed to sell firearms to a licensed gun Law enforcement, who will accept all prohibited dealer. To do so, the gun dealer must present a bill of sale items and may store them or destroy them; to your local law enforcement agency. The law OR enforcement agency will give the licensed gun dealer the A licensed gun dealer, who can buy or store items that you are selling. firearms. If you have firearm parts, call ahead for more information. Do I have to prove that I have turned in, sold, or stored the prohibited items? When do I have to turn in, sell, or store the Yes. Within 48 hours you must file a receipt with the courtprohibited items? showing that you have surrendered the prohibited items toImmediately, if law enforcement asks you for the items. a law enforcement agency or sold them to or stored themOtherwise, within 24 hours. with a licensed gun dealer. You may use Receipt for Who can I turn in, sell, or store the prohibited Firearms and Firearm Parts (form EA-800) for this items with? purpose. Only law enforcement or a licensed gun dealer. You cannot give your prohibited items to a family member, friend, or Additional Questions? anyone else. Contact an attorney for legal advice. Call your local law enforcement agency, for example, your city police or Where can I sell the prohibited items? county sheriff for their procedures. At a licensed gun dealer in your area. You can search the internet for "Gun Dealers" or "Firearms Dealers" to find Information about prohibited items and how to obey these orders is also available online.one. Make sure the dealer is licensed. See https://selfhelp.courts.ca.gov/respond-to-EA- Do I have to pay a fee to store prohibited restraining-order/obey-firearms-orders. items? You may have to pay a fee. Contact your local law For help in your area, contact: enforcement agency or a licensed gun dealer about fees and [Local information may be inserted.] whether they have space to store your items.

Judicial Council of California, www.courts.ca.gov Rev. January 1, 2023, Optional Form How Do I Turn In, Sell, or Store My Firearms EA-800-INFO, Page 1 of 1 Code of Civil Procedure, § 527.9; and Firearm Parts? Welfare and Institutions Code, § 15657.03 (Elder or Dependent Adult Abuse Prevention)

Receipt for Firearms and Firearm Clerk stamps date here when form is filed. EA-800 Parts

1 Protected Person Name:

2 Restrained Person a. Your Name: Your Lawyer (if you have one for this case): Name: State Bar No.: Fill in court name and street address: Firm Name: Superior Court of California, County of b. Your Address (If you have a lawyer, give your lawyer’s information. STANISLAUS If you do not have a lawyer and you want to keep your home address 1100 I STREET private, you may give a different mailing address instead. You do not P.O. BOX 1098 have to give telephone, fax, and email.) MODESTO, CA 95353 Address: City: State: Zip: Court fills in case number when form is filed. Telephone: Fax: Case Number: Email Address:

3 To the Restrained Person:

If a judge has ordered you to turn in, sell, or store your firearms (guns) and firearm parts—meaning receivers,

frames, or any item that may be used as or easily turned into a receiver or frame (see Penal Code section 16531)— use this form to prove to the judge that you have obeyed their orders. Take this form to a law enforcement officer or a licensed gun dealer to complete item 4 or 5 . For more information on how to properly turn in your items, read form CH-800-INFO, How Do I Turn In, Sell, or Store My Firearms and Firearm Parts?

4 To Law Enforcement

(Complete the section below. Keep a copy and give the original to the person in 2 .)
Name of Law Enforcement Agency:
Name of Law Enforcement Agent:
Address:
Telephone: Email Address:

Items Surrendered

a. Firearms and firearm parts transferred on:
Date: Time: a.m. p.m.

b. List of items (List all the items surrendered by the person in 2 . You may attach a separate form from your
agency (e.g., a property report), use item 6 , or both. Check below if you have attached a separate form):
Separate form is attached. (If it does not include all surrendered items, list additional items in item 6 .)

I declare under penalty of perjury under the laws of the State of California that the information above is
true and correct.

Signature of law enforcement agent:

Judicial Council of California, www.courts.ca.gov Rev. January 1, 2023, Optional Form Receipt for Firearms and Firearm Parts EA-800, Page 1 of 3 Code of Civil Procedure, § 527.9; Penal Code § 29830; Welfare and Institutions Code, § 15657.03 (Elder or Dependent Adult Abuse Prevention)

Case Number:

5 To Licensed Gun Dealer

(Complete the section below. Keep a copy and give the original to the person in 2 .)
Name of Licensed Gun Dealer:
License number:
Address:
Telephone: Email Address:

Items Stored or Sold

a. Firearms and firearm parts transferred on:
Date: Time: a.m. p.m.

b. List of items (List all the items surrendered by the person in 2 . You may attach a separate form (e.g.,
Department of Justice’s Report of Firearms Acquisition) or you may use item 6 . Check below if you have
attached a separate form):
Separate form is attached. (If it does not include all surrendered items, list additional items in item 6 .)

I declare under penalty of perjury under the laws of the State of California that the information above is
true and correct.

Signature of licensed gun dealer:

6 List of Items Surrendered

Firearms and firearm parts
Serial Number To be
Make Model if there is one Sold Stored destroyed
(1)
(2)
(3)
(4)
(5)
(6)

Check here if there is not enough space above for your answer. Use a separate sheet of paper to list other items.
Write “EA-800, item 6” at the top, and attach it to this form.

Rev. January 1, 2023 Receipt for Firearms and Firearm Parts EA-800, Page 2 of 3 (Elder or Dependent Adult Abuse Prevention)

Case Number:

7 To the Restrained Person:

Besides the items listed on page 2 or in an attached form, do you have or own any other firearms (guns) or firearm
parts?
No
Yes (If yes, check one of the boxes below):
a. I filed a Receipt for Firearms and Firearm Parts (form CH-800) or other proof for those items with the
court on (date):

b. I am filing the proof for those firearms (guns) and firearm parts along with this proof.

c. I have not yet filed the proof for the other firearms (guns) and firearm parts.
(Explain why not):

Your signature

I declare under penalty of perjury under the laws of the State of California that the information above is true and
correct.

Date:

Type or print your name Sign your name

---

Your Next Steps

After the form is complete, make two additional copies. Take the copies and original to the court clerk to file.

Keep a copy for yourself.

Note that failure to file a receipt with the court is a violation of the court's order.

Rev. January 1, 2023 Receipt for Firearms and Firearm Parts EA-800, Page 3 of 3 (Elder or Dependent Adult Abuse Prevention)