Ch 110 Form – Fill Out and Use This PDF

Under 1 Protected Person, write Your Full Name. If you have a lawyer for this case, write the lawyer's Name, State Bar No. and Firm Name.

Under 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. Fill in Address, City, State and Zip. You do not have to give telephone, fax, or email.

Under 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. The star (*) boxes are Full Name, Age, Race and Gender: M, F or Nonbinary. The other boxes are Date of Birth, Height, Weight, Hair Color, Eye Color, Home Address, City, State, Zip and Relationship to Protected Person.

3 Additional Protected Persons: in addition to the person named in 1, the following family or household members of that person are protected by the temporary orders indicated. For each one, fill in Full Name, Gender, Age, Household Member? Yes or No, and Relation to Protected Person.

Check here if there are additional 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.

Court fills in case number when form is filed.

The court will complete the rest of this form. 4 Expiration Date This order expires at the end of the hearing scheduled for the date and time in Date: and Time: a.m. p.m.

To the Person in 2: The court has granted the temporary orders checked as granted.

To the Person in 2: If you do not obey these orders, you can be arrested and charged with a crime.

5 Personal Conduct Orders: you must not do the following things to the person named in 1 and to the other protected persons listed in 3: Harass, intimidate, molest, attack, strike, stalk, threaten, assault (sexually or otherwise), hit, abuse, 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 email, by text message, by fax, or by other electronic means.

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.

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 Order: you must stay at least yards away from (check all that apply): (1) The person in 1; (2) Each person in 3; (3) The home of the person in 1; (4) The job or workplace of the person in 1; (5) The school of the person in 1; (6) The school of the children of the person in 1; (7) The place of child care of the children of the person in 1; (8) The vehicle of the person in 1; (9) Other (specify).

This stay-away order does not prevent you from going to or from your home or place of employment.

7 No Firearms (Guns), Firearm Parts, or Ammunition: 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 7 b on the next page.

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.

(1) You must sell to or store with a licensed gun dealer, or turn in to a law enforcement agency, any firearms (guns), firearm parts, and ammunition 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), firearm parts, and ammunition have been turned in, sold, or stored. You may use Receipt for Firearms, Firearm Parts, and Ammunition (form CH-800) for the receipt.

9 No Body Armor: 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.

11 Possession and Protection of Animals: the person in 1 is given the sole possession, care, and control of the animals listed in the box, which are owned, possessed, leased, kept, or held by them, or reside in their household. Identify animals by, e.g., type, breed, name, color, sex.

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.

13 c. By the close of business on the date that this order is made, the person in 1 or their lawyer should deliver a copy of the order and its proof-of-service form to the law enforcement agency listed under Name of Law Enforcement Agency and Address (City, State, Zip) to enter into CARPOS.

14 No Fee to Serve (Notify) Restrained Person: the sheriff or marshal will serve this order without charge because: a. The order is based on unlawful violence, a credible threat of violence, or stalking.

b. The person in 1 is entitled to a fee waiver.

Fill in court name and street address: Superior Court of California, County of.

To the Person in 2: You may be sent to jail for up to one year, pay a fine of up to $1,000, or both. (checked November 2, 2026)