Formfva4 - Application to Extennd-Vary-Revoker (Word 205 KB - 3 Pages)
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Form FVIO4
APPLICATION TO EXTEND, VARY OR REVOKE AN INTERVENTION ORDER
Family Violence ProtectionMagistrates’ Act 2008, Sections Court 100-113 of Victoria
In the Children’s Court at Case No
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 FVIO4 (CCV) September 2011 Page 1 of 3 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 Yes No become family members of the respondent since the family violence Name: intervention order was made? 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
FVIO4 (CCV) September 2011 Page 2 of 3 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 X Applicant
Date
For further information contact your local Children’s Court of Victoria or visit www.childrenscourt.vic.gov.au
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 Yes No violence intervention order?
If the protected person is a child, does a parent of the child consent to the variation or extension of the family violence Yes No intervention order?
If the protected person has a guardian, does the guardian consent to the variation or extension of the family violence Yes No intervention order?
Leave of the Court required where respondent to original Yes No proceeding seeks to make application (s 109 FVPA Act):
Leave of the Court required where protected person is a child aged 14 years or more and seeks to make application (s 108 Yes No FVPA Act):
FVIO4 (CCV) September 2011 Page 3 of 3