Domestic and Personal Violence

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Sample Application for Apprehended Domestic Violence Order
This is a sample only. The form you receive will contain information about your case. If you need more help get legal
advice.
Sample only. This is not legal advice

APPLICATION FOR
APPREHENDED DOMESTIC
VIOLENCE ORDER – Gary Smith
Crimes (Domestic and Personal Violence) Act 2007		 Court seal
located here
Details of the applicant (the person making the application)
Name – Const C Arnot
Police application number (if application is made by police) – 123456
Contact details – Waverley Police Station
Details of the protected person or persons ( the persons to be protected by the order)
Name of first person – Elizabeth Smith
Address –
Date of birth/Age – 17 September 1975
Relationship to defendant – The protected person(s) is or has been married to the
defendant.
Name of any other person – Dakota Smith
Address –
Date of birth/Age – 17 August 2009
Note. The address at which a protected health care provider resides must not be stated in this application
unless the protected health care provider consents to the address being included or, if the application is
made by a police officer, the police officer is satisfied that the defendant knows the address.
Details of the defendant (the person against whom the order is sought)
Name – Gary SMITH
Date of Birth/Age – 7 February 1971
Telephone number –
Address –		 04xx xxx xxx
47 Wensleydale Avenue
GREENACRE NSW

Central Name Index (where known) –

NOTICE TO APPLICANT
It is an offence under the Crimes (Domestic and Personal Violence) Act 2007 to make
a statement in this application that you know is false or misleading in a significant
respect.
The maximum penalty for that offence is imprisonment for 12 months and/or a fine of
$1,100.
NOTICE TO DEFENDANT
You are directed to attend the Local Court or Children’s Court of NSW on:
Date: 1 December 20XX
Time: 9:30 AM
Place: Waverley Local Court
151 Bronte Road
WAVERLEY NSW

Case Number: 20XX/00001221
Sample only. This is not legal advice
Page 2 of 3
If you fail to attend, the court may make orders against you or issue a warrant for your arrest to
bring you before the court.
Reasons for making this application and the duration sought
The applicant is seeking an apprehended domestic violence order for the period of 2 years.
The reasons the applicant is making an application for an apprehended domestic violence order
and seeks the period specific above are as follows –
The applicant and the defendant have been married for 4 years. There is one 18 month old child of
the relationship. The parties formerly resided together at 12/100 Victoria Road, Double Bay.
Following the incidents described in this application, the defendant moved out. The daughter lived
with the applicant.
The defendant is currently unemployed after losing his job as a salesman 4 months ago. The
applicant is employed as a nurse at the Wayside Mercy Medical Centre.
On Sunday 3 April 20XX the defendant and applicant were at home. Their daughter was asleep in
her cot in the bedroom. The defendant and applicant were arguing in the lounge room about their
financial situation. The defendant started yelling at the applicant, calling her ‘lazy’ and ‘useless’.
The applicant tried to leave the room but the defendant blocked her path. The defendant then
pushed the applicant, causing her to fall over onto her right arm. The applicant felt a sharp pain in
her arm and later attended Prince of Wales Hospital where she was advised that she had a
fractured ulna (forearm).
The defendant left the house immediately after the argument. He returned at approximately
10.00AM the following day to collect some belongings. He then moved out of the house.
The applicant fears for her safety, as the defendant has pushed her in the past and often loses his
temper.
Further information about the relationship between the applicant and the defendant
Note. This section is not required to be completed if this application is made by the police.

1. Are you currently involved in any legal proceedings under the
Family Law Act 1975 of the Commonwealth that may be
relevant?
If the answer is “Yes”, give details –		 Yes No
2. Has the court made a property order or are property orders
currently being sought under the Family Law Act 1975 of the
Commonwealth that may be relevant?
If the answer is “Yes”, give details –		 Yes No
3. Has the court made a parenting order under the Family Law Act 1975
of the Commonwealth of that affects this application?
If the answer is “Yes”-
On what basis was the parenting order made –
Why should the court intervene with that parenting order –		 Yes No

Case Number: 20XX/00001221
Sample only. This is not legal advice
Page 3 of 3
The applicant asks that the court make the following orders against the defendant –
The standard orders that the applicant asks the court to make
Orders about behaviour
1. The defendant must not do any of the following to the protected person(s) or anyone the protected
person(s) has a domestic relationship with –
(a) Assault or threaten them, and
(b) Stalk, harass or intimidate them, and
(c) Intentionally or recklessly destroy or damage any property that belongs to or is in the possession
of them.
Additional orders that the application asks the court to make (tick if required)
Orders about contact
2 The defendant must not approach or contact the protected person(s) in any way, unless contact is
through a lawyer.
3 The defendant must not approach –
(a) the school or any other place the protected person(s) might go to for study, or
(b) any place the protected person(s) might go to for childcare, or
(c) any other place listed here –

4 The defendant must not approach or be in the company of the protect person(s) within at least 12
hours after drinking alcohol or taking illicit drugs.

5 The defendant must not try to find the protected person(s), except as ordered by a court.
Orders about family law and parenting
6 The defendant must not approach or contact the protected person(s) in any way, unless contact is–
(a) through a lawyer, or
(b) to attend accredited or court-approved counselling, mediation and/or conciliation, or
(c) ordered by the court or another court about contact with the child/children, or
(d) as agreed in writing between the defendant and the parent(s) about contact with the
child/children, or
(e) as agreed in writing between the defendant, the parent(s) and the person with parental
responsibility for the child/children about contact with the child/children.
Note. Order 6(e) is an alternative to order 6(d).
Orders about where defendant cannot go
7 The defendant must not live at –
(a) the same address as the protected person(s), or
(b) any place listed here –
8 The defendant must not go into –
(a) any place where the protected person(s) lives, or
Case Number: 20XX/00001221
Sample only. This is not legal advice
Page 4 of 3
(b) any place where the protected person(s) works, or
(c) any place listed here –
9 The defendant must not go within 100 metres of –
(a) any place where the protected person(s) lives, or
(b) any place where the protected person(s) works, or
(c) any place listed here – 12/100 Victoria Road, Double Bay
Orders about weapons
10 The defendant must not possess any firearms or prohibited weapons.
Other orders
11 [List other orders].
Signature of the applicant –

Date – 15 November 20XX

 

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