<p> Form FVIO4</p><p>APPLICATION TO EXTEND, VARY OR REVOKE AN INTERVENTION ORDER</p><p>Family Violence ProtectionMagistrates’ Act 2008, Sections Court 100-113 of Victoria</p><p>In the Children’s Court at Case No </p><p>APPLICANT Address </p><p>Contact Number </p><p>PROTECTED PERSON Address </p><p>Contact Number </p><p>Do you wish to disclose your address? Yes No</p><p>RESPONDENT Address </p><p>Contact Number </p><p>ADDITIONAL APPLICANT Address </p><p>ADDITIONAL RESPONDENT Address </p><p>I SEEK TO:</p><p> extend the order vary the order revoke the order Please briefly state the reasons for the application</p><p>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)</p><p>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?</p><p>If you wish to vary the order, what changes do you seek?</p><p>If you wish to extend the order, please specify the duration of the extension sought.</p><p>Date of making of the family violence </p><p> intervention order</p><p>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 </p><p>Name: Male Female Date of Birth Relationship to Respondent </p><p>Name: Male Female Date of Birth Relationship to Respondent </p><p>Name: Male Female Date of Birth Relationship to Respondent </p><p>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.</p><p>SIGNATURE OF APPLICANT </p><p>Signature of X Applicant </p><p>Date </p><p>For further information contact your local Children’s Court of Victoria or visit www.childrenscourt.vic.gov.au</p><p>COURT USE ONLY (Leave & Consent Requirements)</p><p>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?</p><p>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?</p><p>If the protected person has a guardian, does the guardian consent to the variation or extension of the family violence Yes No intervention order?</p><p>Leave of the Court required where respondent to original Yes No proceeding seeks to make application (s 109 FVPA Act):</p><p>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):</p><p>FVIO4 (CCV) September 2011 Page 3 of 3 </p>