APPLICANT
Address
Contact Number
PROTECTED PERSON
Address
Contact Number
Do you wish to disclose your address? / Yes No
RESPONDENT
Address
Contact Number
ADDITIONAL APPLICANT
Address
ADDITIONAL RESPONDENT
Address
I SEEK TO:
extend the order
vary the order
revoke the order
Please briefly state the reasons for the application
This application is made by: /
Applicant for original intervention order
Protected person
Parent of protected person
Respondent
Additional protected person
Additional Respondent
Police officer (not applicant in original proceeding)If you are the respondent, you must demonstrate a change in circumstances since the intervention order was made. What do you say about any change of circumstances?
If you wish to vary the order, what changes do you seek?
If you wish to extend the order, please specify the duration of the extension sought.
Date of making of the family violence intervention order
Are there any other persons who have become family members of the respondent since the family violence intervention order was made? / Yes No
Name:
Male Female / Date of Birth
Relationship to Respondent
Name:
Male Female / Date of Birth
Relationship to Respondent
Name:
Male Female / Date of Birth
Relationship to Respondent
Name:
Male Female / Date of Birth
Relationship to Respondent
Details of any relevant Family Law Act order or child protection order, or any current application for a relevant Family Law Act order or child protection order.
SIGNATURE OF APPLICANT
Signature of
Applicant / X
Date
For further information contact your local Magistrates’ Court of Victoria or visit
COURT USE ONLY (Leave & Consent Requirements)If the protected person is not the applicant, does the protected person consent to the variation or extension of the family violence intervention order? / Yes No
If the protected person is a child, does a parent of the child consent to the variation or extension of the family violence intervention order? / Yes No
If the protected person has a guardian, does the guardian consent to the variation or extension of the family violence intervention order? / Yes No
Leave of the Court required where respondent to original proceeding seeks to make application (s 109FVPA Act): / Yes No
Leave of the Court required where protected person is a child aged 14 years or more and seeks to make application (s 108 FVPA Act): / Yes No
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