Form 28B INFORMATION Court Use (CHILD PROTECTION RESTRAINING Date Filed: ORDER) Magistrates Court of South Australia Summary Procedure Act 1921 Section 99AAC Informant Name / relationship to child Informant’s reference Street Telephone Facsimile Address City/Town/Suburb State Postcode Email Address Defendant DOB Name dd/mm/yyyy Street Telephone Licence Number Address City/Town/Suburb State Postcode Email Address Child for whose benefit order is sought DOB Name dd/mm/yyyy The informant says that the defendant: the defendant is an adult who is, or has been, residing with the above-named child who is under the age of 17 years of whom the defendant is not a guardian; And the defendant and the above-named child are, or have been, residing at premises other than premises in which a guardian of the child resides; And the defendant or another person who resides at, or frequents, premises at which the defendant and the child reside or have resided – has, within the preceding 10 years, been convicted of the prescribed offence(s) of or is, or has at any time been, subject to a restraining order under section 99AAC; Or as a consequence of the above-mentioned or residence with the defendant, the child is at risk child’s contact of – sexual, physical, psychological, or emotional abuse or neglect; or engaging in, or being exposed to, conduct that is an offence under Part 5 of the Controlled Substances Act 1984 And that the making of the order is appropriate in the circumstances.
Form 28B INFORMATION (CHILD PROTECTION RESTRAINING ORDER) Magistrates Court of South Australia Summary Procedure Act 1921 Section 99AAC Court Use Date Filed: Informant Name Informant’s reference / relationship to child Address Street Telephone Facsimile City/Town/Suburb State Postcode Email Address Defendant Name DOB dd/mm/yyyy Address Street Telephone Licence Number City/Town/Suburb State Postcode Email Address Child for whose benefit order is sought Name DOB dd/mm/yyyy The informant says that the defendant: the defendant is an adult who is, or has been, residing with the above-named child who is under the age of 17 years of whom the defendant is not a guardian; And the defendant and the above-named child are, or have been, residing at premises other than premises in which a guardian of the child resides; And the defendant or another person who resides at, or frequents, premises at which the defendant and the child reside or have resided – has, within the preceding 10 years, been convicted of the prescribed offence(s) of or is, or has at any time been, subject to a restraining order under section 99AAC; Or as a consequence of the above-mentioned child’s contact or residence with the defendant, the child is at risk of – sexual, physical, psychological, or emotional abuse or neglect; or engaging in, or being exposed to, conduct that is an offence under Part 5 of the Controlled Substances Act 1984 And that the making of the order is appropriate in the circumstances.
Form%2028B%20-%20Information%20(Child%20Protection%20Restraining%20Order).docx