FILED

2022 JUL 05
KING COUNTY
SUPERIOR COURT CLERK

CASE #: 22-2-10378-7 SEA

Superior Court of Washington, County of King

Jenny Lu 05/04/1995 Case No.
22-2-10378-7 SEA
Petitioner (Person starting this case) DOB
Petition for Protection Order
vs. Clerk’s Action: 1
Angelo Prado 10/09/1985

Respondent (Person responding to this case) DOB

Petition for Protection Order

What kind protection order do you want? There are different orders based on the type of
harm and how the parties know each other. See definitions in Attachments A and B.

1. Choose the type of protection order that best fits your situation. Check only one.
[ ] Domestic Violence – Protection from an intimate partner or family or household
member who has committed domestic violence,
nonconsensual sexual conduct or penetration, unlawful
harassment, or stalking. (PTORPRT)
[ ] Sexual Assault – Protection from someone who has committed sexual
assault. (PTORSXP)
[ ] Stalking – Protection from someone who has committed stalking.
(PTORSTK)
[ ] Vulnerable Adult – Protection from someone who has abandoned, abused,
financially exploited, or neglected a vulnerable adult (or
threatened to do so). (PTORVA)
Important! If you are asking for a Vulnerable Adult Protection Order, you
must complete Attachment B: Vulnerable Adult as part of this Petition.
[ ] Anti-Harassment – Protection from someone who has committed unlawful
harassment. (PTORAH) (fee required)
The conduct also includes (if applicable): [ ] stalking [ ] hate crime
[ ] single act/threat of violence including malicious and intentional threat

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 or presence of firearm/weapon causing substantial emotional distress
[ ] family or household member engaged in domestic violence
[ ] nonconsensual sexual conduct or penetration or a sex offense
2. If more than one of the protection order types listed above fits your situation, list
any additional order types here:

Who are the people involved? These are the "parties" to the case.

3. Who should the order restrain? ("Restrained Person")

Name: Angelo Prado
Restrained Person's age: [ ] Under 13 [ ] 13 to 17 [ ] 18 or over [ ] unknown
4. Who should the order protect? (“Protected Person") (Check all that apply.)
[ ] Me. My name is Jenny Lu
(You must be age 15 or older.)
[ ] Minor Children.
[ ] I am the minor’s [ ] parent [ ] legal guardian [ ] custodian.
[ ] I am age 18 or older and the minor is a member of my family or household.
(For domestic violence petitions only.)
[ ] I am age 15 to 17. The minor is a member of my family or household. I have been
chosen by the minor and am capable of pursuing their stated interest in this case.
Child's Name Age Sex Lives With How related to you How related to
Restrained Person

Important! If the restrained person is a parent of any of the children, complete Attachment C: Child Custody.
If you are not a parent of any of the children, complete Attachment D: Non-parents protecting children (ICWA).
You must include these Attachment/s with your Petition if they apply.

[ ] Someone else. (List your name as Petitioner at the beginning of this form. Describe
who you are filing for here.) I am filing to protect:
[ ] a vulnerable adult (name)
(See definition and complete Attachment B.)
[ ] an adult (name)
who does not meet the definition of a vulnerable adult, but who cannot file the
petition themselves because of age, disability, health, or inaccessibility
(Do not check this for vulnerable adult or domestic violence petitions.).
What is the age, disability, health or inaccessibility concern that makes the
adult unable to file themselves? (Examples: the adult is hospitalized,
temporarily incapacitated, or in jail/prison.)

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5. Service address. What is your address for receiving legal documents? You have the
right to keep your residential address private. You may use a different mailing address.
Mail:
1525 9th Ave, Apt 2307, Seattle, WA 98101

Email (if you agree to be served by email): jennylu95.13@gmail.com

6. Interpreter
Do you need an interpreter? [ ] No [ ] Yes, Language:
Important! You may need to request an interpreter separately. You will get instructions with an order setting
your hearing.

How do the parties know each other?

7. Check all the ways the protected person is connected or related to the restrained person:
Intimate Partners – Protected person and restrained person are intimate partners
because they are:
[ ] current or former spouses or domestic partners
[ ] parents of a child-in-common (unless child was conceived through sexual assault)
[ ] current or former dating relationship (age 13 or older) who
[ ] never lived together [ ] live or have lived together
Family or household members - Protected person and restrained person are family or
household members because they are:
[ ] parent and child [ ] stepparent and stepchild
[ ] parent’s intimate partner and child [ ] grandparent and grandchild
[ ] current or former cohabitants as roommates
[ ] person who is or has been a legal guardian
[ ] related by blood or marriage (specify how)
Other (examples: coworker, neighbor, acquaintance, stranger)

Connection to Washington State. This helps decide if the court has authority (jurisdiction).

8. Why are you filing in this county and state? Check all that apply.
[ ] The protected person lives in this county now, or used to live in this county but left
because of abuse.
[ ] An incident that made me want this protection order happened in this county or state.
9. Restrained Person's residence. Where does the restrained person live?
[ ] In Washington State in (city or county): 2116 4th Ave, Apt 3918, Seattle, WA 98121
[ ] Outside of Washington State [ ] Unknown
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 Are there other court cases involving the parties or any children?

10. Other court cases. Have there been any other court cases between any of the people
involved in this case or about any children? Include court cases happening now and in
the past and requests for protection that were denied or have expired. (Examples: criminal
no contact order, civil protection order, family law restraining order, protection order from another state,
tribal order, military orders, parenting plans, divorce, landlord-tenant, employment, property, assault, police
investigations. File copies in this court case of everything you want the court to review.)
[ ] No [ ] Yes. If yes, fill out below.
Type of Case Court Location Court Type (Superior Case Number Status (active /
(see examples) (City or County / District / Municipal / (if known) dismissed / pending /
and State) Tribal / Military) expired, unknown)

Other details:

What protections do you need? Check everything you want the court to order.

11. I ask for a protection order with these restraints:

General Restraints
A. [ ] No Harm: Do not cause any physical harm, bodily injury, assault, nonconsensual
sexual conduct or nonconsensual sexual penetration, and do not harass, threaten, or
stalk [ ] protected person [ ] the minors named in section 4 above
[ ] these minors only:
B. [ ] No Contact: Do not make any attempts or have any contact, including nonphysical
contact, directly, indirectly, or through third parties, regardless of whether those third
parties know of the order, except for service of court documents with
[ ] protected person [ ] the minors named in section 4 above
[ ] these minors only:
[ ] Exception (if any): Only this type of contact is allowed:

C. [ ] Exclude and Stay Away: Do not enter, return to, knowingly come within, or
knowingly remain within 1,000 feet or other distance (specify)
of
[ ] the protected person [ ] protected person’s vehicle
[ ] protected person’s school [ ] protected person’s workplace
[ ] protected person’s residence [ ] protected person’s adult day program
[ ] the shared residence
[ ] the residence, daycare, or school of [ ] the minors named in section 4 above
[ ] these minors only:
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 Pro Club Bellevue (4455 148th Ave NE, Bellevue, WA 98007); Pro Club Seattle
[ ] other: (501 Eastlake Ave E, Seattle, WA 98109)
Address: The protected person chooses to (check one)
[ ] keep their address confidential [ ] list their address here:

D. [ ] Vacate shared residence: The protected person has exclusive right to the
residence that the protected person and restrained person share. The restrained
person must immediately vacate the residence. The restrained person may take the
restrained person’s clothing, personal items needed during the duration of the order,
and these items (specify):
from the residence while a law enforcement officer is present.
E. [ ] Stalking Behavior: Do not harass, follow, monitor, keep under physical or electronic
surveillance, cyber harass (as defined in RCW 9A.90.XXX), or use phone, video,
audio or other electronic means to record, photograph, or track locations or
communication, including digital, wire, or electronic communication of
[ ] the protected person [ ] the minors named in section 5 above
[ ] these minors only:
[ ] these members of the protected person's household :

F. [ ] Intimate Images: Do not possess or distribute intimate images of a protected person,

as defined in RCW 9A.86.010. The restrained person must take down and delete all
intimate images and recordings of a protected person in the restrained person’s
possession or control and cease any all disclosure of those intimate images.
G. [ ] Electronic Monitoring: The restrained person must submit to electronic monitoring.
(Restrained person must be age 18 or older.)
H. [ ] Evaluation: The restrained person shall get an evaluation for:
[ ] mental health [ ] chemical dependency (drugs)
I. [ ] Treatment: The restrained person shall participate in state-certified treatment for:
[ ] sex offender [ ] domestic violence perpetrator
J. [ ] Personal Belongings: The protected person shall have possession of essential
personal belongings, including the following:

K. [ ] Transfer of Assets: Do not transfer jointly owned assets.

L. [ ] Vehicle: The protected person shall have use of the following vehicle:
Year, Make & Model License No.
M. [ ] Restrict Abusive Litigation: Do not engage in abusive litigation as set forth in
chapter 26.51 RCW or in frivolous filings against the protected person, making
harassing or libelous communications about the protected person to third parties, or
making false reports to investigative agencies.
N. [ ] Pay Fees and Costs: The restrained person must pay fees and costs of this action.
This may include administrative court costs, service fees, and the protected person’s
costs including lawyer fees.

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Firearms and Other Dangerous Weapons
O. [ ] Surrender Weapons: The restrained person must immediately surrender to law
enforcement and not access, possess, have in their custody or control, purchase,
receive, or attempt to purchase or receive firearms, other dangerous weapons, or
concealed pistol licenses.
Important! The court may be required to order the restrained person to surrender firearms, other dangerous
weapons, or concealed pistol licenses even if you do not request it.
Does the restrained person have or own firearms?
[ ] Yes [ ] No [ ] Unknown
Would the restrained person’s use of firearms or other dangerous weapons be a serious
and immediate threat to anyone's health or safety?
[ ] Yes [ ] No [ ] Unknown
Even if the restrained person does not have firearms now, has the restrained person
ever used firearms, other weapons or objects to threaten or harm you?
[ ] Yes [ ] No
If Yes, describe what happened.

Is the restrained person already not allowed to have firearms?

[ ] Yes [ ] No [ ] Unknown
If Yes, why?

Minors
P. [ ] Custody: The protected person is granted temporary care, custody and control of
[ ] the minors named in section 4 above
[ ] these minors only:
(Only for children the protected and restrained person have together.)
Q. [ ] Interference: Do not interfere with the protected person's physical or legal custody of
[ ] the minors named in section 4 above
[ ] these minors only:
R. [ ] Removal from State: Do not remove from the state:
[ ] the minors named in section 4 above
[ ] these minors only:
S. [ ] School Attendance: Do not attend the elementary, middle, or high school (school
name) , that a protected person attends.
(Only if both the restrained person and a protected person are students at the same
school. Can apply to students 18 or older. Includes public and private schools.)

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 Describe any continuing physical danger, emotional distress, or educational
disruption to a protected person that would happen if the restrained person attends
the same school.

Pets
T. [ ] Custody: The protected person shall have exclusive custody and control of the
following pet/s owned, possessed, leased, kept, or held by the protected person,
restrained person, or a minor child who lives with either the protected or restrained
person. (Specify name of pet and type of animal.):

U. [ ] Interference: Do not interfere with the protected person’s efforts to get the pet/s
named above.
V. [ ] Stay Away: Do not knowingly come within, or knowingly remain within
(distance)
of the following locations where the pet/s are regularly found:
[ ] Protected person's residence (home address may be kept confidential.)
[ ] Other (specify):

Vulnerable Adult
W. [ ] Safety: Do not commit or threaten to commit acts of abandonment, neglect, financial
exploitation, or abuse, including sexual abuse, mental abuse, physical abuse, personal
exploitation, and improper use of restraints, against the vulnerable adult.
X. [ ] Accounting: Provide an accounting of the disposition of the vulnerable adult’s income
or other resources.
Y. [ ] Property Transfer: Do not transfer the property of [ ] the vulnerable adult [ ] the
restrained person. This restraint can last for up to 90 days.

Other
Z.

Do you need help from law enforcement? They may help you get the things you asked for.
12. Law Enforcement Help: Do you want the court to order the appropriate law
enforcement agency to help you with any of the things listed below?
Check all that apply.
[ ] Possession of my residence.
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 [ ] Possession of the vehicle I asked for in section L above.
[ ] Possession of my essential personal belongings that are located at
[ ] the shared residence
[ ] the restrained person’s residence
[ ] other location
[ ] Custody of [ ] the minors named in section 4 above
[ ] these minors only
[ ] Other:

How long do you need this order to last?

13. Length of Order

(The order will last for at least one year unless you ask for something different. Orders
restraining a parent from contacting their own children may not exceed one year.)
I need this order to last for: [ ] 1 year [ ] more than 1 year [ ] less than 1 year (specify
how long):
If you checked more or less than one year, briefly explain why.
Due to repeated and persistent threats over several years, asking for at least 2 years protection.

Do you need immediate protection? If needed, you can ask for a Temporary Protection
Order that starts now, before the restrained person gets notice. This protection can last up to
14 days or until the court hearing (whichever comes first).

14. Immediate Protection: Do you need a Temporary Protection Order to start immediately,
without prior notice to the restrained person? [ ] Yes [ ] No
15. Immediate Weapons Surrender: Do you want a temporary order that requires the
restrained person give up all firearms, other dangerous weapons, and concealed pistol
licenses right away, and prohibits the restrained person from getting more?
[ ] Yes [ ] No
If Yes to 14 or 15, explain why: What serious immediate harm or irreparable injury could occur
if an order is not issued immediately without prior notice to the restrained person?
(Briefly explain how you or anyone else might be harmed if you do not get protection now.)
The respondent has made numerous, progressively explicit and serious threats over several months.
The abuse has temporarily stopped due to the respondent being out of town traveling, but he is due to
return this week and has threatened to act upon his threats upon his immediate return.

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 Why do you need a protection order? What happened? This is your statement, where you
tell your experience.
Be as specific and descriptive as possible. Put the date, names, what happened and where.
Use names rather than pronouns (he/she/they) as much as possible. If you cannot remember
the date, put the time of year it happened (around a holiday, winter, summer, how old your
child was) or about how long ago.
For all of the questions below, include details:
 Who did what?
 When did this happen?
 How were any statements made? (in person, mail, text, phone, email, social media)
 How did this make you, the minor, or the vulnerable adult feel?
If you need more space to answer any of the questions below, use form PO 010 Statement or
attach additional pages.
16. Most Recent Incident. What happened most recently that made you want a protection
order? This could include violent acts, fear or threats of violence, coercive control,
nonconsensual sexual conduct or penetration, sexual abuse, harassment, stalking, hate
crimes. For a vulnerable adult, include incidents or threats of abandonment, abuse,
neglect and/or financial exploitation. Include specific date/s and details of the incident.
Angelo has demonstrated a repeated pattern of threats and attempts at restraining me from leaving.
Angelo and I were former dating partners for the 2-3 years, during which I attempted numerous times to
end our relationship due to coercive control and emotional and sexual abuse. Previous attempts to end
the relationship were met by threats (detailed below) and forced restraint. My last attempt to end our
relationship was on 6/10/22.

Most recently, on 6/18/22, Angelo arranged for a meeting in a public location to discuss my demands
for ceasing-contact. We met at Rey Amargo (722 E Pike St, Seattle, WA), during which our
conversation became heated and I stated my intention to leave. Angelo physically attempted to block
me from leaving. I eventually exited the building, and he followed me and demanded we continue the
conversation at Noren (320 E Pike St, Seattle, WA). There, while seated at the restaurant, he verbally
berated me and threatened me with legal action, disciplinary action with my employer (Angelo is my
direct manager at work), social humiliation, and harassment against my friends and family. There were
multiple witnesses, including our waiter (contact information can be provided). I expressed fear,
distress, and desperation. I left the building again, at which point Angelo followed me on the street,
continuing to threaten me by calling a mutual coworker to "expose" me. On the streets, he physically
intimidated me by cornering me against buildings and dashing after me when I broke into a run. He
then dialed my coworker multiple times and put him on speaker phone. My friend who I called for help
then intervened and we left together to go to my apartment (Angelo is listed as a restricted persons by
my building security). Angelo took another route and appeared at my apartment while we were outside,
verbally accosted me and my friend, and made several more threats before leaving.

Threats he made has included filing expensive, extensive legal action against me, sending humiliating
materials to my ex-dating partners, repeatedly texting my friends, exposing my professional
inexperience/"incompetence" to my coworkers, "watching and following me forever" and "making my life
a miserable, inconvenient hell."

17. Past Incidents. What happened in the past that makes you want a protection order?
This could include violent acts, fear or threats of violence, coercive control,
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 nonconsensual sexual conduct or penetration, sexual abuse, harassment, stalking, hate
crimes. For a vulnerable adult, include incidents or threats of abandonment, abuse,
neglect and/or financial exploitation. Include specific date/s and details of the incidents.
I have been in a multi-year coercive relationship with Angelo characterized by extreme psychological
and emotional abuse, financial control, and reputational and social threats. Angelo has isolated and
removed me from my friends and family (he arranged for my employment under his direct
management and relocated me from New York to Washington in February 2022), weakening my
support system. He took advantage of me when I was economically vulnerable from being
unemployed to offer me employment, and has subsequently repeatedly threatened firing and
reputational harm (“blacklisting me from the industry”) if I do not comply with his demands. He then
used the power and authority he has over me at work to coercively force me into several
cross-country and international trips, destabilizing my living routine and basic living functions (eating,
sleeping). He has held me against my will in several locations (his apartment, hotel rooms, public
locations). Threats he has made include vivid descriptions of the suffering I will endure once I "have
no one to support me" in my life, the hopelessness of my career prospects without his help,
destitution without either a paid job or his financial support, and emotional battery over my "
worthlessness". There has been coerced, nonconsensual sexual activity. I have been receiving
treatment since at least May 2021 for emotional trauma and acute treatment with multiple providers
since April 2022 for psychological harm (including PTSD), all of whom can substantiate claims of
stalking and domestic violence.

During an attempt in April 2022 to leave the relationship, I indicated my intent not to interact or speak
to him further (I took a leave of absence from work to avoid seeing him there). Angelo responded by
messaging me repeatedly on numerous platforms (iMessage, WhatsApp, Signal) despite receiving no
responses back or being blocked, as well as messaging my friends (e.g. on LinkedIn). He found the
contact information of multiple friends and a former dating partner and threatened to message them "
exposing me". While estranged, he used work resources to ask coworkers to message me to "check
in on me".
When I ignored his messages, Angelo began stalking me at various locations that he knew I
frequently went to. He showed up to my apartment unannounced on 4/25 and was asked to leave and
added to the Restricted list. He traveled across the country and again showed up uninvited at an
event on my birthday in New York on 5/4 (Tuome - 536 E 5th St, New York, NY) where he accosted
me and my friend in public until he was asked to leave. He later revealed that he had turned location
services sharing On in my phone while it was left unlocked. On 5/16 he showed up at my gym (Pro
Club Bellevue - 4455 148th Ave NE, Bellevue, WA) and demanded to speak, threatening self-harm or
reputational harm if I did not comply. During these episodes, he repeatedly threatens further stalking
and economic harm (such as to have me fired from work, or costly legal action).
18. Medical Treatment. Describe any medical treatment you received for issues related to
your request for protection.
I have been seeking treatment for depression since May 2021 due to psychological and emotional
harm from the relationship. Since April 2022, I have been seeking treatment for PTSD, major
depression, anxiety, insomnia, and panic due to the effects of the stalking and verbal threats.

19. Suicidal Behavior. Describe any threats of self-harm or suicide attempts by the
restrained person.

20. Restrained Person’s Substance Abuse

Is substance abuse involved? [ ] Yes [ ] No [ ] Unknown
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If yes, what type of substance abuse? [ ] Alcohol [ ] Drugs [ ] Other

21. Minors Needing Protection, if any (If the information is not already included above.)
Has there been any violence or threats towards children? How have the children been
affected by the restrained person’s behavior? Were the children present during any of
the incidents described above? Describe and give details.

22. Supporting Evidence (If you have anything else you want the court to see that helps
prove what you are saying is true.)
[ ] I am attaching the following evidence to this Petition (check all that apply):
[ ] Pictures
[ ] Text / email / social media messages
[ ] Voice messages (written transcript)
[ ] Written notes / letters / mail
[ ] Police report
[ ] Declaration or statement from witness (name/s):

[ ] Other (describe):

Privacy Warning! The restrained person will see this Petition and any other evidence you file
with the court. This information is also available to the public for anyone to see.
Before you file any attachments, you can black out (redact) any sensitive information.
Examples: your home address and account numbers (leave last four digits).

I certify under penalty of perjury under the laws of the state of Washington that all the
information provided in this petition and any attachments is true and correct.
[ ] I have attached (number):____11 pages.

Signed at (City and State): Seattle, WA Date: 07/05/2022

Jenny Lu
Sign here Print name

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Attachment A: Definitions
"Domestic violence" means: Evidence of emission of semen is not required to
(a) Physical harm, bodily injury, assault, or the prove sexual penetration.
infliction of fear of physical harm, bodily injury, or "Stalking" means any of the following:
assault; nonconsensual sexual conduct or (a) Any act of stalking as defined under RCW
nonconsensual sexual penetration; coercive 9A.46.110;
control; unlawful harassment; or stalking of one
intimate partner by another intimate partner; or (b) Any act of cyber harassment as defined under
RCW 9A,90.XXX; or
(b) Physical harm, bodily injury, assault, or the
infliction of fear of physical harm, bodily injury, or (c) Any course of conduct involving repeated or
assault; nonconsensual sexual conduct or continuing contacts, attempts to contact,
nonconsensual sexual penetration; coercive monitoring, tracking, surveillance, keeping under
control; unlawful harassment; or stalking of one observation, disrupting activities in a harassing
family or household member by another family or manner, or following of another person that:
household member. (i) Would cause a reasonable person to feel
"Sexual conduct" means any of the following: intimidated, frightened, under duress,
significantly disrupted, or threatened and that
(a) Any intentional or knowing touching or fondling of actually causes such a feeling;
the genitals, anus, or breasts, directly or indirectly,
including through clothing; (ii) Serves no lawful purpose; and
(b) Any intentional or knowing display of the genitals, (iii) The respondent knows, or reasonably should
anus, or breasts for the purposes of arousal or know, threatens, frightens, or intimidates the
sexual gratification of the respondent; person, even if the respondent did not intend
to intimidate, frighten, or threaten the person.
(c) Any intentional or knowing touching or fondling of
the genitals, anus, or breasts, directly or indirectly, "Unlawful harassment" means:
including through clothing, that the petitioner is (a) A knowing and willful course of conduct directed
forced to perform by another person or the at a specific person that seriously alarms, annoys,
respondent; harasses, or is detrimental to such person, and
(d) Any forced display of the petitioner's genitals, that serves no legitimate or lawful purpose. The
anus, or breasts for the purposes of arousal or course of conduct must be such as would cause a
sexual gratification of the respondent or others; reasonable person to suffer substantial emotional
distress, and must actually cause substantial
(e) Any intentional or knowing touching of the clothed emotional distress to the petitioner; or
or unclothed body of a child under the age of 16, if
done for the purpose of sexual gratification or (b) A single act of violence or threat of violence
arousal of the respondent or others; or Any directed at a specific person that seriously alarms,
coerced or forced touching or fondling by a child annoys, harasses, or is detrimental to such
under the age of 16, directly or indirectly, including person, and that serves no legitimate or lawful
through clothing, of the genitals, anus, or breasts purpose, which would cause a reasonable person
of the respondent or others. to suffer substantial emotional distress, and must
actually cause substantial emotional distress to
"Sexual penetration" means any contact, however the petitioner. A single threat of violence must
slight, between the sex organ or anus of one person include:
by an object, the sex organ, mouth, or anus of another
person, or any intrusion, however slight, of any part of (i) A malicious and intentional threat as
the body of one person or of any animal or object into described in RCW 9A.36.080(1)(c); or
the sex organ or anus of another person including, but (ii) the presence of a firearm or other weapon.
not limited to, cunnilingus, fellatio, or anal penetration.

RCW 7.105 Petition for Protection Order

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Attachment B: Vulnerable Adult
Does your case involve a vulnerable adult? If yes, complete this attachment and submit it as
part of your petition. If no, skip this attachment.

1. What qualifies the adult as a vulnerable adult? The adult (check all that apply):
[ ] Is over 60 years old and does not have the functional, mental, or physical ability to
care for himself or herself.
[ ] Is an individual subject to guardianship under 11.130.25 or an individual subject to
conservatorship under 11.130.360 RCW
[ ] Has a developmental disability as defined in RCW 71A.10.020.
[ ] Self-directs their own care and receives services from a personal aide under RCW
74.39.
[ ] Is receiving services from a home health, hospice, or home care agency licensed or
required to be licensed under RCW 70.127.
[ ] Is receiving in-home services from an individual provider under contract with DSHS.
[ ] Has been admitted to an assisted living facility, nursing home, adult family home,
soldiers’ home, residential habilitation center or any other facility licensed by DSHS.
2. Does the vulnerable adult know you will be filing this petition?
[ ] Yes [ ] No If no, what efforts did you make to notify the vulnerable adult?

3. Connection to Washington. Does the vulnerable adult live in Washington State?

[ ] Yes [ ] No If no, are you asking to protect any family members of the vulnerable
adult who:
 Live in Washington State, and
 Have been affected by the restrained person's actions
[ ] Yes [ ] No
4. What is your relationship to the vulnerable adult?
[ ] DSHS is filing this petition for a vulnerable adult who [ ] has consented [ ] lacks
capacity or ability to consent to this petition.
[ ] I am the vulnerable adult’s guardian/conservator, or limited guardian/conservator.
I was appointed in (county and state)
in Case Number
on or about (date)
(Attach a copy of your letters or order appointing guardian/conservator, if available.)
[ ] To protect the vulnerable adult, I imposed an emergency restriction on the
vulnerable adult’s right to associate with the restrained person on (date)

RCW 7.105.100, .110 Petition for Protection Order

(7/2022) Attachment B: Vulnerable Adult
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 [ ] I am the vulnerable adult’s legal fiduciary. I was appointed [ ] trustee [ ] power of
attorney on or about (date) .
(Attach a copy of your relevant documents, if available.)
[ ] I am interested in the welfare of the vulnerable adult. I have a good faith belief that
the court’s intervention is necessary and that the vulnerable adult is unable at this
time to protect their own interests, due to incapacity, undue influence, or duress.
What is the nature of your relationship to the vulnerable adult? How long has this
relationship lasted? (Describe)

What is the incapacity, undue influence, or duress that makes the vulnerable
adult unable to protect their own interests? (Describe)

Definitions For Vulnerable Adult Protection Orders:

"Vulnerable adult" includes a person: vulnerable adult. In instances of abuse of a vulnerable
(a) Sixty years of age or older who has the adult who is unable to express or demonstrate
functional, mental, or physical inability to care for physical harm, pain, or mental anguish, the abuse is
himself or herself; or presumed to cause physical harm, pain, or mental
anguish.
(b) Subject to a guardianship under RCW
11.130.265 or adult subject to conservatorship "Abuse" includes sexual abuse, mental abuse,
under RCW 11.130.360; or physical abuse, personal exploitation, and improper
use of restraint against a vulnerable adult, which
(c) Who has a developmental disability as defined have the following meanings:
under RCW 71A.10.020; or
(a) "Improper use of restraint" means the
(d) Admitted to any facility; or inappropriate use of chemical, physical, or
(e) Receiving services from home health, hospice, or mechanical restraints for convenience or
home care agencies licensed or required to be discipline, or in a manner that:
licensed under chapter 70.127 RCW; or (i) Is inconsistent with federal or state licensing
(f) Receiving services from a person under contract or certification requirements for facilities,
with the department of social and health services hospitals, or programs authorized under
to provide services in the home under chapter chapter 71A.12 RCW;
74.09 or 74.39A RCW; or (ii) is not medically authorized; or
(g) Who self-directs his or her own care and receives (iii) otherwise constitutes abuse under this
services from a personal aide under chapter section.
74.39 RCW.
(b) "Mental abuse" means an intentional, willful, or
"Abuse," for the purposes of a vulnerable adult reckless verbal or nonverbal action that
protection order, means intentional, willful, or reckless threatens, humiliates, harasses, coerces,
action or inaction that inflicts injury, unreasonable intimidates, isolates, unreasonably confines, or
confinement, intimidation, or punishment on a punishes a vulnerable adult. "Mental abuse" may
RCW 7.105.100, .110 Petition for Protection Order
(7/2022) Attachment B: Vulnerable Adult
PO 001 p. 3 of 3
 include ridiculing, yelling, swearing, or income, resources, or trust funds of the
withholding or tampering with prescribed vulnerable adult for the benefit of a person or
medications or their dosage. entity other than the vulnerable adult; or
(c) "Personal exploitation" means an act of forcing, (c) Obtaining or using a vulnerable adult's property,
compelling, or exerting undue influence over a income, resources, or trust funds without lawful
vulnerable adult causing the vulnerable adult to authority, by a person or entity who knows or
act in a way that is inconsistent with relevant past clearly should know that the vulnerable adult
behavior, or causing the vulnerable adult to lacks the capacity to consent to the release or
perform services for the benefit of another. use of the vulnerable adult's property, income,
(d) "Physical abuse" means the intentional, willful, or resources, or trust funds.
reckless action of inflicting bodily injury or "Neglect" means:
physical mistreatment. "Physical abuse" includes, (a) A pattern of conduct or inaction by a person or
but is not limited to, striking with or without an entity with a duty of care that fails to provide the
object, slapping, pinching, strangulation, goods and services that maintain the physical or
suffocation, kicking, shoving, or prodding. mental health of a vulnerable adult, or that fails to
(e) "Sexual abuse" means any form of avoid or prevent physical or mental harm or pain
nonconsensual sexual conduct including, but not to a vulnerable adult; or
limited to, unwanted or inappropriate touching, (b) an act or omission by a person or entity with a
rape, molestation, indecent liberties, sexual duty of care that demonstrates a serious
coercion, sexually explicit photographing or disregard of consequences of such a magnitude
recording, voyeurism, indecent exposure, and as to constitute a clear and present danger to the
sexual harassment. "Sexual abuse" also includes vulnerable adult's health, welfare, or safety
any sexual conduct between a staff person, who including, but not limited to, conduct prohibited
is not also a resident or client, of a facility or a under RCW 9A.42.100.
staff person of a program authorized under
chapter 71A.12 RCW, and a vulnerable adult
living in that facility or receiving service from a
program authorized under chapter 71A.12 RCW,
whether or not the sexual conduct is consensual.
"Financial exploitation" means the illegal or
improper use of, control over, or withholding of, the
property, income, resources, or trust funds of the
vulnerable adult by any person or entity for any
person's or entity's profit or advantage other than for
the vulnerable adult's profit or advantage. "Financial
exploitation" includes, but is not limited to:
(a) The use of deception, intimidation, or undue
influence by a person or entity in a position of
trust and confidence with a vulnerable adult to
obtain or use the property, income, resources,
government benefits, health insurance benefits,
or trust funds of the vulnerable adult for the
benefit of a person or entity other than the
vulnerable adult;
(b) The breach of a fiduciary duty, including, but not
limited to, the misuse of a power of attorney,
trust, or a guardianship or conservatorship
appointment, that results in the unauthorized
appropriation, sale, or transfer of the property,
RCW 7.105.100, .110 Petition for Protection Order
(7/2022) Attachment B: Vulnerable Adult
PO 001 p. 3 of 3
Attachment C: Child Custody
Are you asking to protect any of the restrained person’s children? [ ] Yes [ ] No
If Yes, complete this attachment and file it as part of your petition. If No, skip this attachment.

Does a Washington Court have authority over the children? Before the court can protect
a child, you must tell the court about the children's connection to Washington State. See
instructions for help.

1. Children’s Home/s
At any time during the past 5 years have the children lived:
 on an Indian reservation,
 outside Washington state,
 in a foreign country, or
 with anyone who is not a party to this case?
[ ] No. (Skip to 2)
[ ] Yes. (Fill out below to show where the children have lived during the last 5 years.)
In which state,
Dates Children Lived with Indian reservation,
or foreign country

From: [ ] All children [ ] Petitioner [ ] Respondent

To: [ ] (Initials): [ ] Other (name):
From: [ ] All children [ ] Petitioner [ ] Respondent
To: [ ] (Initials): [ ] Other (name):
From: [ ] All children [ ] Petitioner [ ] Respondent
To: [ ] (Initials): [ ] Other (name):
From: [ ] All children [ ] Petitioner [ ] Respondent
To: [ ] (Initials): [ ] Other (name):
From: [ ] All children [ ] Petitioner [ ] Respondent
To: [ ] (Initials): [ ] Other (name):

2. Other people with a legal right to spend time with the children
Do you know of anyone besides yourself and Respondent who has or claims to have a
legal right to spend time with the children?
[ ] No.
[ ] Yes. (Name/s) has or claims to have
a legal right to spend time with the children because:

3. Authority over the children (Jurisdiction) (RCW 26.27.201 – .221, .231, .261, .271)
The court can make an order protecting the children because:

RCW 7.105.100, Petition for Protection Order

26.27.201-.291 Attachment C: Child Custody
(7/2022) p. 1 of 2
PO 001
 [ ] Exclusive, continuing jurisdiction – A Washington court has already made a
custody order or parenting plan for the children, and the court still has authority to
make other orders for the children.
[ ] Home state jurisdiction – Washington is the child’s home state because
(check all that apply):
[ ] The children lived in Washington with a parent or someone acting as a parent
for at least the 6 months just before this case was filed, or if a child is less than
6 months old, the child has lived in Washington with a parent or someone
acting as a parent since birth.
[ ] There were times the children were not in Washington in the 6 months
just before this case was filed (or since birth if a child is less than 6
months old), but those were temporary absences.
[ ] The children do not live in Washington right now, but Washington was the
children’s home state sometime in the 6 months just before this case was
filed, and a parent or someone acting as a parent of the children still lives in
Washington.
[ ] The children do not have another home state.
[ ] No home state or home state declined – No court of any other state (or tribe) has
the jurisdiction to make decisions for the children or a court in the children’s home
state (or tribe) decided it is better to have this case in Washington and:
 The children and a parent or someone acting as a parent have ties to
Washington beyond just living here; and
 There is a lot of information (substantial evidence) about the children’s care,
protection, education, and relationships in this state.
[ ] Other state declined – The courts in other states (or tribes) that might be the
children’s home state have refused to take this case because it is better to have this
case in Washington.
[ ] Temporary emergency jurisdiction – The court can make decisions for the
children because the children are in this state now and were abandoned here or
need emergency protection because the children (or their parent, brother, or sister)
was abused or threatened with abuse. (Check one):
[ ] A custody case involving the children was filed in the children’s home state
(name of state or tribe): . Washington
should take temporary emergency jurisdiction over the children until the
Petitioner can get a court order from the children’s home state (or tribe).
[ ] There is no valid custody order or open custody case in the children’s home
state (name of state or tribe): . If no case is
filed in the child’s home state (or tribe) by the time the children has been in
Washington for 6 months, (date): , Washington
should have final jurisdiction over the children.
[ ] Other reason (specify):

RCW 7.105.100, Petition for Protection Order

26.27.201-.291 Attachment C: Child Custody
(7/2022) p. 2 of 2
PO 001
Attachment D: Non-Parents Protecting Children (ICWA)
Are you asking to protect any children who are not your own? [ ] Yes [ ] No
If Yes, complete this attachment and file it as part of your petition. If No, skip this attachment.

Non-Parents must comply with the Indian Child Welfare Acts (ICWA). If you are not a
legal parent of a minor child you are asking to protect, you must find out if the minor is or may
be an Indian child. If so, the federal and state Indian Child Welfare Acts will apply to your
case. This does not apply to parents.
Parents: you do not have to answer these questions about your own children.

1. Tribal Heritage
If there is a reason to know that a child has tribal heritage (including ancestry or familial political affiliation),
the court must treat the child as an Indian child unless and until the affected tribe/s decide otherwise or
decline to respond after receiving proper notice.
An Indian child is a child who is a member of an Indian tribe, or who is the biological child of an Indian tribe
member and is eligible for membership. Tribes decide their own membership.
Could any of the children be Indian children? (Check all that apply)
[ ] No. These children are not Indian children (name/s):
I know this because (Explain if the children have no tribal heritage, or if any
possible tribal heritage has already been explored and decided in another court
proceeding that complied with ICWA. Attach orders):

[ ] Yes or maybe. These children are or may be Indian children. They have or may
have heritage from the tribe/s listed below:
Children Tribes
[ ] All [ ] (name/s):
[ ] All [ ] (name/s):

I will provide the Indian Child Welfare Act Notice (form GDN M 401) and a copy of
this Petition to the tribe/s named above and other necessary people or agencies.
[ ] I do not know if any of the children are Indian children or have tribal heritage. I have
done the following things to find out:

RCW 7.105.105 Petition for Protection Order

(7/2022) Attachment D: Non-parents Protecting Children (ICWA)
PO 001 p. 1 of 2
 Warning! You must find out if any of these children have tribal ancestry before a full order is issued.
2. Authority Over Indian Children (Jurisdiction)
[ ] Does not apply. None of the children are Indian children.
[ ] A state court can decide this case for any children who are or may be Indian children
because:
[ ] (Children’s Initials): are not domiciled or living
on an Indian reservation, and are not wards of a tribal court. (25 USC §1911)
[ ] (Children’s Initials): are domiciled or living on an
Indian reservation, and (check all that apply):
[ ] The children’s tribe agrees to Washington State’s concurrent jurisdiction.
[ ] The children’s tribe decided not to use its exclusive jurisdiction (expressly
declined). (RCW 13.38.060)
[ ] Washington State should exercise emergency jurisdiction for Indian
children temporarily located off the reservation to protect the children from
immediate physical damage or harm. (RCW 13.38.140)

RCW 7.105.105 Petition for Protection Order

(7/2022) Attachment D: Non-parents Protecting Children (ICWA)
PO 001 p. 2 of 2