Clerk stamps date here when form is filed.
Fill in court name and street address:
EA-109,
Page 1 of 3
Notice of Court Hearing
(Elder or Dependent Adult Abuse Prevention)
Judicial Council of California, www.courts.ca.gov
New January 1, 2012, Mandatory Form
Welfare and Institutions Code, § 15657.03
Approved by DOJ
Court fills in case number when form is filed.
Notice of Court Hearing
2
Person You Want Protection From
Full Name:
Superior Court of California, County of
Case Number:
Full Name:
1
Elder or Dependent Adult in Need of Protection
Lawyer for person named above (if any for this case):
Name:
State Bar No.:
Firm Name:
3
Full Name:
Person requesting protection for the elder or dependent adult, if
different (person named in item of Form EA-100):
Address for person named above (If you have a lawyer, give your
lawyer’s information. If you do not have a lawyer, give information
for the person requesting the order. If you want to keep your home
address private, you may give a different mailing address instead.
You do not have to give telephone, fax, or e-mail.):
a
.
Zip:
State:
City:
Telephone:
Fax:
E-Mail Address:
Address:
Notice of Hearing
A court hearing is scheduled on the request for restraining orders against the person in :
3
Name and address of court if different from above:
Date: Time:
Room:Dept.:
Hearing
Date
2
Temporary Restraining Orders for personal conduct and stay-away orders as requested in Form EA-100,
Request for Elder on Dependent Adult Abuse Restraining Orders are (check only one box below):
All GRANTED until the court hearing.
a
.
All DENIED until the court hearing. (Specify reasons for denial in b, below.)
Partly GRANTED and partly DENIED until the court hearing. (Specify reasons for denial in
b, below.)
(1)
(2)
(3)
Temporary Restraining Orders (Any orders granted are on Form EA-110, served with this notice.)
4
The court will complete the rest of this form.
EA-109
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