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Here is the text we could read:

JV-258

Request for Juvenile Restraining
Order Against a Child

Clerk stamps date here when form is filed.

When to use this form
Use this form if you want a restraining order against a child or youth in a
juvenile justice (delinquency) case. If you have a lawyer in this case, the
lawyer should fill out this form for you. If you want a restraining order in a
juvenile case but against someone who is not the child, use form JV-245,
Request for Juvenile Restraining Order.

1 Person in Need of Protection

Fill in court name and street address:

Superior Court of California, County of

a. Name:

b. Age:

(If you are a lawyer asking for a restraining order for someone else,
like a victim in this case, write your name below in e. If additional
people need to be protected, list them in .)

Address where you can receive court papers

(This address will be used by the court and by the person in to
send you official court dates, orders, and papers. For privacy, you
may use another address like a post office box or another person’s
address, if you have their permission and can get your mail regularly.
If you have a lawyer, give their address.)

Address:

City:

d. Contact Information

State:

Zip:

Fill in child's name
Child's name:

Court fills in case number when form is filed.

Case Number:

(The court could use this information to contact you, If you don't want the person in to have this information,
leave it blank or provide a safe phone number or email address. If you have a lawyer give their information.)

Telephone:

Email Address:

Fax:

Lawyer Making This Request (if not the person in a)1
Title:

Name:

Firm Name:

State Bar No.:

2 Child or Youth to Be Restrained

a. Name:

b. Date of birth (if known):
c. Gender: Male
d. Race:
e. Relationship to person in a:1

Female

Age (give estimate, if age unknown):

Nonbinary

Judicial Council of California,
New January 1, 2023, Mandatory Form
Family Code § 6389;
Welfare and Institutions Code, §§ 213.5, 213.7, 726.5;
Cal. Rules of Court, rules 5.625, 5.630

Request for Juvenile Restraining Order
Against a Child

JV-258, Page 1 of 5

This is not a Court Order.

Case Number:

3 Describe Why You Need a Restraining Order

a. Did the person in do any of these things to the person in a?
(cid:254) Check all that apply

(Note: These are only some examples of why someone might need a restraining order.)

Physically hurt or tried to physically hurt

Sexually abused or tried to sexually abuse

Used or threatened to use gun or weapon

Stalked

Harassed by phone, online, or by any other means

Isolated the person in a from friends or family
1

Kept the person in a from eating or getting other basic needs

Destroyed property (examples: breaking phone, door, window)

Other (please explain):

b. Give details about what the person in did that was abusive or harassing. Start with the most recent

incident, then write about any other incidents. Be sure to include details like dates and any emotional or physical
harm. Details can also include how often something happened, what was said, or whether weapons were used,
etc.

Check here if you need more space to describe abuse or harassment. Attach a sheet of paper and write "JV-258,
Item 3" at the top.

Check here if you know there is a report that supports your request that has been filed with the court,
and complete the section below.
Who wrote the report and when was the report filed? (Check all that apply.)

Social worker (date report was filed):
Probation officer (date report was filed):

Other (name):

(date report was filed):

New January 1, 2023

Request for Juvenile Restraining Order
Against a Child

JV-258, Page 2 of 5

This is not a Court Order.

Case Number:

4 Do Other People Need Protection From the Person in ?2

No
Yes (If yes, give their information below.)

a. Full name

Age

Relationship to the child

b. Why do these people need protection?

2
5 Did You Provide Notice to the Person in of This Request for a Restraining Order?
(Skip this item if your request is based on domestic violence. To know what domestic violence is, see form
DV-500-INFO, page 2, "Am I Eligible?")

No (If no, complete the section below.)

(1)

I did not notify the person in or their lawyer because I am afraid that the person in will threaten or
harm the person in a if they receive notice of this request before protection can be granted (explain):

(2)

Other (describe):

Yes (If yes, complete section below.)

(1) Who did you notify?
(2) When did you provide notice?
(3)

Person in 2
(date):

How did you provide notice? (Check all that apply.)

Lawyer of person in 2
(time):

Telephone (list number):
Email or other electronic means (specify):

Other (describe):

Fax (list number):

a.m.

p.m.

Does the Person in Have Firearms (Guns), Firearm Parts, or Ammunition?
(A firearm includes a handgun, rifle, shotgun, and assault weapon. A firearm part means a receiver, frame, or
unfinished receiver or unfinished frame. Ammunition includes bullets, shells, cartridges, and clips.)
a.
b.
c.

I don’t know
No
Yes (If you have information, complete the section below.)

Describe firearms, firearm parts, or ammunition

Location, if known

How many or
what amount?

(1)
(2)

New January 1, 2023

This is not a Court Order.

Request for Juvenile Restraining Order
Against a Child

JV-258, Page 3 of 5

Choose the Orders That You Want a Judge to Make

In this section, you will choose the orders you want a judge to make now. Every situation is different.
Check all the orders that you want the judge to make (order).

Case Number:

Order to Not Abuse

I ask the judge to order the person in to not threaten, stalk, or disturb the peace of me or anyone listed
in . 4

If this restraining order is needed to prevent domestic violence, “disturbing the peace” includes coercive
control. For more information on what domestic violence, disturbing the peace, and coercive control mean, read
form DV-500-INFO, page 2, "Am I Eligible?"

No-Contact Order

I ask the judge to order the person in to not contact me or any person listed in .

Protect Animals

a. (You may ask the judge to protect animals that you own or are keeping for others, animals that the people in
4
own or are keeping for others, and animals that anyone who lives with you or the people in own or are
keeping for others.)

Name (or other way to ID animal) Type of animal

Breed (if known)

Color

(1)
(2)
(3)
(4)

(2)

(3)

b. I ask the judge to protect the animals listed above by ordering the person in to:

(Check all that apply)

(1)

Stay away from the animals by at least:

100 yards (300 feet)

Other (give distance in yards):

Not take, sell, hide, molest, attack, strike, threaten, harm, get rid of, transfer, or borrow against the
animals.

Give the me possession, care, and control of the animals because (check all that apply):

Person in abuses the animals.
I purchased these animals.

I take care of these animals.
Other (please explain):

New January 1, 2023

Request for Juvenile Restraining Order
Against a Child

JV-258, Page 4 of 5

This is not a Court Order.

Case Number:

Automatic Orders if the Judge Grants Restraining Order

10 No Firearms (Guns), Firearm Parts, or Ammunition

If the judge grants a restraining order, the person in will have to turn in, sell, or store any firearms (guns),
2
firearm parts, or ammunition that the person has or controls. The person in would also be prohibited from
buying firearms (guns), firearm parts, and ammunition.

11 Cannot Look for Protected People and Others

If the judge grants a restraining order, the person in will not be allowed to look for the address or location
2
of any person protected by the restraining order or the address or location of family members, caretakers, or
guardians of the protected people, unless the court finds good cause to not make this order.

12 Additional Pages

If you used additional paper or forms, enter the number of extra pages attached to this form:

13 Your Signature

I declare under penalty of perjury under the laws of the State of California that the information above is true and
correct.
Date:

Type or print your name

Sign your name

14 Your Lawyer's Signature (if you have one)

Date:

Lawyer’s name

Lawyer’s signature

Your Next Steps

u You must complete two additional forms:

Form JV-260, Notice of Court Hearing and Temporary Restraining Order Against a Child (only items 1, 2,
and 3)

Form CLETS-001, Confidential CLETS Information

v Turn in your completed forms to the court. Find out when your forms will be ready for pickup.

New January 1, 2023

Request for Juvenile Restraining Order
Against a Child

JV-258, Page 5 of 5

This is not a Court Order.

JV-258 Request for Juvenile Restraining Order Against a Child

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the California state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from selfhelp.courts.ca.gov (2023-03)
Page(s): 5
Fields(s): 129
Average fields per page: 25
Reading Level: Grade 6
LIST Grouping(s): CO-00-00-00-00, CO-07-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

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JV-258 Request for Juvenile Restraining Order Against a Child

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