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Affidavit of Family Violence

  1. EXHIBIT “A” INCIDENTS OF FAMILY VIOLENCE

  2. As grounds for this Application for a Protective Order, Applicant would show that Respondent has engaged in the following acts of family violence (explain the acts or threats of violence to you and/or to others, including details of where the incidents occurred, who was present, what injuries you sustained and any treatment for those injuries and if you called the police what action took place).

  3. STATE OF TEXAS, COUNTY OF BRAZOS

  4. Before me, the undersigned authority, on this day personally appeared the undersigned Applicant who, being by me duly sworn, upon oath stated: I am the Applicant in the foregoing Application for Protective Order. All the following acts and occurrences are true and correct within my personal knowledge:

  5. I, the undersigned, state under oath that I am the Applicant in the foregoing Application, that I have personal knowledge of the facts and allegations stated in it, and they are true and correct to the best of my knowledge and belief.

  6. After filling out the rest of this form, please print form and sign here.

  7. SUBSCRIBED AND SWORN TO BEFORE ME, the undersigned Notary Public on the

  8. day of

  9. Print form and have Notary sign here

  10. Leave This Blank: