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CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR Located at City/County Case No. Court Address vs. Name of Respondent on Original Court Order Name of Petitioner on Original Court Order Street Address Apt. No. Home Work Telephone City State Zip Code PETITION TO MODIFY/RESCIND PROTECTIVE ORDER I the Respondent in the above entitled case ask this Court to modify the Protective Order in this case dated Petitioner Person Eligible for Relief as follows rescind the Protective Order in this case dated My reasons are extend the Protective Order due to a subsequent act of abuse. CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR Located at City/County Case No* Court Address vs. Name of Respondent on Original Court Order Name of Petitioner on Original Court Order Street Address Apt. No* Home Work Telephone City State Zip Code PETITION TO MODIFY/RESCIND PROTECTIVE ORDER I the Respondent in the above entitled case ask this Court to modify the Protective Order in this case dated Petitioner Person Eligible for Relief as follows rescind the Protective Order in this case dated My reasons are extend the Protective Order due to a subsequent act of abuse. I want relief for myself minor child vulnerable adult from abuse by. Name The Respondent committed the following acts of abuse against on or about check all that apply by kicking punching Date choking/strangling slapping shooting rape or other sexual offense or attempt hitting with object stabbing shoving threats of violence mental injury of child detaining against will stalking other The details of what happened are Describe injuries. State when and where these acts occurred* Be as specific as you can* Signature CERTIFICATE OF SERVICE I hereby certify that on the day of Month I mailed a copy of this Petition to Year Name and Address CC-DC/DV 6 Rev* 10/2010 Page 1 of 2 ----------------------------------------------------------------------------------- Date ----------------------------------------------------- ORDER OF COURT It is this --------------- day of ORDERED that this matter be scheduled for a hearing. the Petition is Denied because ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Judge Reset. No* Home Work Telephone City State Zip Code PETITION TO MODIFY/RESCIND PROTECTIVE ORDER I the Respondent in the above entitled case ask this Court to modify the Protective Order in this case dated Petitioner Person Eligible for Relief as follows rescind the Protective Order in this case dated My reasons are extend the Protective Order due to a subsequent act of abuse. I want relief for myself minor child vulnerable adult from abuse by. Name The Respondent committed the following acts of abuse against on or about check all that apply by kicking punching Date choking/strangling slapping shooting rape or other sexual offense or attempt hitting with object stabbing shoving threats of violence mental injury of child detaining against will stalking other The details of what happened are Describe injuries.

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