Preparing an Application About a

Protection Order
Form 12
Provincial Court Family Rules
Complete this the form to ask the Provincial Court for a protection order under Part 9 of the Family Law Act or to change or
terminate an existing protection order.
A protection order made under the Family Law Act is a court order that protects one family member from another family member if there
is a risk of family violence. The order usually lists conditions the person named in it must follow. For example, a protection order may
include a condition that the family member not have contact or communicate directly or indirectly with the family member that needs
protection. It is a criminal offense for the person named in the protection order to disobey (breach) any conditions in the order. If they do,
the police can enforce the order under the Criminal Code and the person may face significant consequences.
A protection order will expire on the date a judge orders for it to end. If the judge doesn’t order a specific end date, it expires one year
after the date it is made.
You can complete the application about a protection order form if you require protection for yourself and/or your child, or you can apply
on behalf of another adult.
You can also complete an application about a protection order form if you want to ask the court to change or cancel an existing
protection order.
There is no limit on protection order applications. Another application can be made if an application was denied, the terms of an order
need to be changed, or an order has expired and another one is needed.

Legal Assistance

Understanding the law and making sure you get correct information is important. If you get the wrong information or do not know how
the law applies to your situation, and proceed to court without legal advice, it may be harder to resolve your case. Getting advice from a
lawyer can help.
Free legal advice – to find out if you qualify for Family Duty Counsel or Family LawLINE services – contact Legal Aid BC at 1-866-577-
2525 or go to https://legalaid.bc.ca/legal_aid/legalAdvice.
Legal Aid BC – to see if you qualify for free legal representation, call 604-408-2172 (Greater Vancouver) or 1-866-577-2525 (elsewhere in
BC) or go to https://legalaid.bc.ca/legal_aid/legalRepresentation.
Lawyers – To find a lawyer to hire or to have a free consultation with a lawyer for up to 30 minutes, contact the Lawyer Referral Service
at 1-800-663-1919 or go to https://www.accessprobono.ca/our-programs/lawyer-referral-service
Family Law information and Resources – Visit https://family.legalaid.bc.ca/ for free information, or Clicklaw at www.clicklaw.bc.ca/
helpmap to find other free and low-cost legal services in your community.

Help is available

If you have safety concerns about family violence, you may want to talk to a support worker. VictimLinkBC is a confidential, multilingual
telephone service available 24 hours a day, 7 days a week at 1-800-563-0808. Victim services workers can provide crisis support,
information and referrals to supports including safety planning, victim services, transition houses and counselling services.

What you need to get started

Try to collect as much information as possible before you start to complete the form.
You might need:
• birth dates, names, and other related information about the other party and your children
• any agreements or court orders you already have about protection or a family law matter
• information about the date(s) you started living together, got married, separated and were divorced, if applicable
• dates and details of any family violence incidents, if applicable

PFA 720 10/2022

Form 12
Step 1: Complete the Application about a Protection Order form
This form is available online at www.gov.bc.ca/court-forms or at any Provincial Court Registry.
You can complete the form online and print it for filing. You can also complete it by hand. If you complete it by hand, be sure it’s readable.
Registry staff and staff at any Justice Access Centre or Family Justice Centre can help answer questions about the forms but they
cannot help complete your forms or give advice about legal problems. If you need help filling in the forms and do not have a lawyer, ask
the court registry staff or staff at the Justice Access Centre of Family Justice Center to refer you to someone who can help.
You need to complete and file the main part of the form and only the schedule that applies to your application.
Follow the instructions in the form. You will be given space to provide information that is important to support your application.
To prepare the form for filing:
• collect the schedule you completed, any existing orders or agreements as referenced in the form, and any additional documents,
if applicable
• print or make copies of all documents: one set for you, one set for the Court, and one set for each other party
• staple each package of documents together
• bring all copies to the court registry for filing or send by mail or by fax filing using the Fax Filing Cover Page Form 52

Step 2: Determine if you should apply without notice

You normally need to give notice to the other party that you are applying for a court order. You give notice to the other party by having
the application documents personally served on them.
Under some circumstances, an application about a protection order may be made without notice to the other party. For example, it may
not be reasonable to give the other person notice (serve them with a copy of the application documents) before the application is heard
by the court if:
• you or your children are in imminent danger of harm; or
• providing notice in advance would probably have serious consequences.
If you are making an application about a protection order without notice, you will have to satisfy the court that there is a real risk of
some danger or serious consequence if notice were required before your order is made. If you apply for an order without notice, the
application will be heard right away. The judge will decide if the order can be made without notice, if notice must be given, or if the notice
period should be shortened. The time between the day that a party is served and the day that the application is heard is called the
“notice period” or “notice”. Normally, the other party must be served with at least 7 days’ notice of the court appearance. A judge can also
allow for an application to be served with less than 7 days’ notice.

Step 3: If applicable, get the Schedule 1 affidavit sworn/affirmed and signed with a commissioner for taking affidavits
The Schedule 1 Affidavit must be signed with a commissioner for taking affidavits. They will need to see your photo ID and they will ask
you to promise that the information in the application affidavit is true.
Lawyers and notaries are all commissioners for taking affidavits. The court registry also has staff who are commissioners for taking
affidavits who can swear or affirm your affidavit for free.
If you cannot get the document sworn or affirmed before the document is filed, the unsworn document can be filed if you will be
available to swear or affirm that the contents of the document are true during your court appearance.

Step 4: File your application and any supporting materials

You must file at the Provincial Court Registry:
• where your existing Provincial Court case with the same parties is filed
• nearest to where you or the other person who needs protection lives, or
• nearest to where the child(ren) ordinarily live, if you fear for the safety of your children or there are children named in an existing
protection order.
If your situation is urgent and you need to file the application about a protection order in another location, the court can give you
permission to file the application at any Provincial Court Registry in the province. You can ask for permission using the Application for
Case Management Order Without Notice or Attendance Form 11.
The registry clerk will review your package to make sure it is complete before filing it. You will be given a copy for your records.
The registry will work with you to schedule a date for the court appearance. If you are making your application without notice and it is
urgent, be prepared to wait at the courthouse after filing your application for your court appearance. Depending on the day, it can take
some time to find an available judge and get you before the court, but they will make sure your application is heard as soon as possible.
There are no court fees for filing Provincial Court family documents.
Step 5: Unless you are making your application without notice to the other party, arrange for personal service of the
Application About a Protection Order on each other party
Service is the act of giving or leaving documents with the required person. It is important that each other party know that a case is going
on, are aware of what step is being taken, and are given a chance to tell their side of the story to the court.
You must arrange to have the other party personally served a copy of the documents with at least 7 days' notice of the date and time
of the court appearance, unless the court has ordered something else. This means there must be at least 7 days between the date the
documents are served on the other party and the date and time of the court appearance.
An adult (at least 19 years old), who is not a party to the case, must personally serve the application about a protection order by hand-
delivering a copy of the application to the other party.
You may ask a friend, family member, or other adult person to personally serve the documents for you. You can also hire a person,
called a process server, to serve the documents for you. Process servers are experienced in finding and serving people. To find a
process server, search the Internet or look in the yellow pages.
The court may need proof you had the documents personally served. The person serving the documents must complete a Certificate
of Service Form 7 so that you can prove personal service of the documents took place. You must attach a copy of the documents to the
Certificate of Service. Remember to make a copy before the documents are served.

Step 6: Attend the Court Appearance

A judge can make decisions based only on the information presented by the parties as evidence. Your evidence includes your
application, any additional affidavit, and spoken evidence provided in court.
If you have a lawyer, they will come to court with you and assist during the hearing.
If you do not have a lawyer, you may find it helpful to bring a trusted friend or family member with you to provide emotional support, take
notes, and organize documents during your court appearance. The Provincial Court has adopted Support Person Guidelines that explain
when you are permitted to have a support person help you, and what they can do.
If you are attending at the courthouse in person for your court appearance, make a safety plan. If the other party is also attending, they
will probably be close by. You can talk to a sheriff as part of your safety planning. The sheriff’s office is available by phone. For contact
information visit Courthouse Locations on the BC Government website at www.gov.bc.ca.
Your safety plan should include going to and from the courthouse.
If you can’t attend court using the method of attendance set out in your application for the court appearance, you can request the court’s
permission to attend using a different method of attendance by filing an Application for Case Management Order without Notice or
Attendance Form 11.

Once a protection order is made

An order takes effect at the time it is made unless ordered otherwise. That means that the person identified in the protection order must
follow the conditions of the order from the moment the judge makes the order in court.
Registry staff are usually responsible for drafting the protection order and getting it signed by the judge. The registry will then provide
a copy to you, any other party who attended the court appearance, and the Protection Order Registry. The Protection Order Registry
keeps a record of all protection orders. Police officers can contact them to check if a protection order is in place and get a copy of the
order.
It is important for the person identified in the protection order to know that there is a protection order in place and what they must do or
not do. If they were not in court when the order was made, the order must be personally served on them so they are aware of it. Registry
staff will help to facilitate personal service of the protection order on the other party if they are in British Columbia. There is no fee for this
service. If they are outside BC, you will need to arrange for them to be served.
To facilitate service, you must provide the registry with information about where the person may be found. To do this, you must complete
a Request for Service of Family Protection Order form and give it to the registry.
Once the protection order has been served, a copy of the proof of service will be sent to the Protection Order Registry.
A police officer may take action to enforce a protection order whether or not there is proof that the order has been served on the person.
If a protection order is not being followed, the police can enforce it under the Criminal Code. Call 911 for help.
A protection order will expire on the date a judge orders for it to end. If the judge doesn’t order a specific end date, it expires one year
after the date it is made.
There is no limit on protection order applications. Another application can be made if an application was denied, the terms of an order
need to be changed, or an order has expired and another one is needed.
For more information visit Information on Protection Orders on the BC Government website at www.gov.bc.ca.

Help is available
If you have safety concerns about family violence, you may want to talk to a support worker. VictimLinkBC is a confidential, multilingual
telephone service available 24 hours a day, 7 days a week at 1-800-563-0808. Victim services workers can provide crisis support,
information and referrals to supports including safety planning, victim services, transition houses and counselling services.
 Tips for Completing the Form:
Registry location and court file number –
Registry staff will give your case a file number when you file this document. You don’t have to fill this in now unless you already have
a case. If you do, copy this information from the top right corner of one of your filed court documents.

Information about the parties –

Party names:
• provide your legal names, including your middle names, from your birth certificate or through a legal name change
• a maiden name or married name can be used as a legal family name unless the name was legally changed
• if you or the other party go by another name, such as a usual name you would prefer to be called by, you can include it after
the full name by including AKA (also known as)
Example: If your legal name is Robert Paul Smith but you are known as Bob Smith, your name should be given as Robert Paul Smith
AKA Bob Smith
Provide your date of birth by indicating mmm/dd/yyyy example: Jan 12 1977 or January 12, 1977
If the date of birth of the other party is not known indicate Unknown
If you already have a court file, you should use the same name you have used for other applications. Copy your name from the first
document you filed in your case.
Lawyer (if applicable) –
Some lawyers are hired for a limited purpose. For example, you may hire a lawyer only to give you legal advice, help you to
complete court documents, or come to a court appearance with you. You will still be responsible for all other aspects of your case.
If you hire a lawyer on a limited scope basis or for unbundled services, make sure you and the lawyer are clear about whether their
name goes on the court documents. Usually it won’t.
If you are a lawyer filling out this form for a client, or if you have a lawyer representing you, the lawyer’s name should be included
and you will usually give their address for service of court documents.
If your income is within the Legal Aid BC's financial guidelines, you may be eligible for a legal aid lawyer to represent you in an
application about a protection order. Legal aid is only available to people who meet the financial eligibility criteria and who need
an immediate court order to ensure the safety of themselves or their children. To find out if you qualify for free legal advice or
representation, contact Legal Aid BC at 1-866-577-2525.

Contact Information –
The court needs to know where to send documents to you and the other party and how to reach each of you.
Address: The court requires an address where you can get mail, but it doesn’t need to be your address.
If you don’t have a stable mailing address, or you are worried about your safety, you may be able to give the address of your lawyer,
a friend or family member, or somewhere that mail can be collected for you.
If you don’t have an address or contact information for the other party, complete as much information as you do know. Talk to the
staff at the court registry about how they might be able to help you find contact information.
Email Address: The quickest way for the court and the other party to contact you is by email. If you give an email address, the court
and the other party can send documents or communicate with you by email instead of using mail. If you can’t or don’t want to use email,
you don’t have to give an email address. Remember, if you agree to use email to receive court documents, you will get copies of court
documents much faster than by mail. Make sure to check your junk box if you are expecting something from the court. Sometimes email
filters will prevent you from receiving an important document.
Telephone number: It is also important for the court to have a telephone number where they can reach you. Make sure the
telephone number is somewhere you can be reached during the day.

Giving notice –
You normally need to give notice to the other party that you are applying for a court order. You give notice to the other party by
having the application documents personally served on them. Under some circumstances, an application about a protection order
may be made without notice to the other party. To apply without notice, you will have to satisfy the court that there is a real risk of
some danger or serious consequence if notice were required before your order is made. Tell the court why you are applying without
notice if you are choosing this option.

Other party –
Note: If you need protection from more than one family member, you should complete an application about a protection order for
each family member you need protection from.
You only need to fill in the contact information you know about the other party. You may leave any part of the contact information
blank.

Applying for an order –

Select if you are applying for a protection order, to change an existing protection order, or to terminate (cancel) an existing protection
order. Complete the required schedule based on the selection you made.

Scheduling –
The registry will work with you to schedule a date for the court appearance and will fill in the actual date and method of attendance
on the form, just be prepared to talk about your availability if there are options for dates.
Application About a Protection Order Registry Location:

Form 12
Court File Number:
Provincial Court Family Rules
Rules 67, 68 and 172

1. My name is . My date of birth is

(full name of party/person) (mmm/dd/yyyy)
My contact information and address for service of court documents by the other party and the court are:

Lawyer (if applicable):

Address:
City: Province: Postal Code:
Email: Telephone:

2. The person I want protection from, or who made an application for protection from me, is the other party. An application is usually
made with notice to the other party. To give notice, they must be served with the application and supporting documents before the date
set for the court appearance. An Application About a Protection Order can also be made without notice to the other party.
Select only one of the options below
I am applying with notice to the other party
I want to apply without notice to the other party because:
Tell the court why the application or your situation is urgent and what you believe will happen if the other party is served
with the application and given a chance to attend court so that you can both be heard at the same time

3. The other party's name is . Their date of birth is

(full name of other party) (mmm/dd/yyyy or unknown)
Their contact information, as I know it, is:

Lawyer (if applicable):

Address:
City: Province: Postal Code:
Email: Telephone:

4. I am applying for the following order:

Select only one of the options below and complete the required schedule

protection order [complete and attach Schedule 1]

order to change an existing protection order [complete and attach Schedule 2]
order to terminate an existing protection order [complete and attach Schedule 3]

For registry use only

This application will be made to the court at

(court registry, street address, city)

on at am/pm.
(date) (time)

You must attend the court appearance (method of attendance) , unless

otherwise allowed by the court. See attached for details.

NOTICE TO THE OTHER PARTY: If you do not attend court on the date and time scheduled for the court appearance, the court
may make an order in your absence. You may also choose to file a written response in reply to the application in Form 19
Written Response to Application.

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Form 12
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PROTECTION ORDER
Complete this schedule if you are applying for a protection order for yourself or on behalf of another person, including your child.
A protection order made under the Family Law Act is a court order to protect a family member from another family member if
there is a risk of family violence.
Family violence includes physical, sexual, and psychological or emotional abuse of a family member. Psychological or emotional
abuse includes intimidation, harassment, coercion, threats, financial abuse, stalking, and intentional damage to property.
In the case of a child, family violence includes witnessing or being exposed to family violence.
Family violence does not include self-defense.
Note: This schedule is an affidavit which means it will need to be sworn or affirmed with a commissioner for taking affidavits. See
the instructions at the beginning of this form for more information on getting the document sworn or affirmed. You may also file the
application without swearing or affirming it if you will be attending the court appearance.

Identification –
Provide your full name, occupation (what you do for a living) and address.
If you have used an address other than your own as your address for service for safety reasons, list the address here as “care of”
or “c/o” the address you are using for service of court documents.

Who needs protection –

Think about who is an at-risk family member that needs protection from the other party.
The Family Law Act defines a family member, in respect of a person, as:
• the person’s spouse or former spouse
• a person with whom the person is living, or has lived, in a marriage-like relationship
• a parent or guardian of the person’s child
• a person who lives with, and is related to the person or a person referred to in the bullets above
• the person’s child
and includes a child who is living with, or whose parent or guardian is, a person referred to above.
Are you worried about your safety only, or also the safety of your children or another family member living with you?
Tell the court who you need the court order to protect. If you are not sure, you may want to talk to a lawyer.
If you are asking for a protection order for your children or another adult family member sharing your residence, provide:
• their full name (usually the name on their birth certificate unless they had a legal name change),
• their date of birth, and
• for a child, their relationship to the other party
• for an adult sharing the residence, their relationship to the other protected person (adult or child)
If you are filing this application on behalf of someone else (instead of just helping them complete the form), then select “other”, give
their name, and explain why you are making the application.
Note: You cannot apply only for the protection of another person's child. If you believe a child needs protection and their parent or
guardian is not willing or able to apply for a Family Law Act protection order on their behalf, contact the Ministry of Children and
Family Development.
 Schedule 1 – Affidavit for Protection Order
This is Schedule 1 to the Application about a Protection Order

This schedule must be completed if you are applying for a protection order. A judge can make decisions based only on the information
presented by the parties as evidence. Evidence must be relevant to the issue.
Please complete the following affidavit to help you explain to the court why you need a protection order and what it should include. In
some cases, if you have provided evidence in this affidavit, a judge may not need you to provide additional information in court.

I, , of ,
full name of party occupation address of party, city, province

SWEAR OR AFFIRM THAT:

1. I am making this affidavit in support of an application for a protection order.

2. I am applying for a protection order for the following person(s) to be protected:

Select and complete only those options that apply to your situation. You may select more than one.
me
the following child(ren) I am parent or guardian to:
Complete only if applicable. You may leave this section blank.
Child’s full legal name Child’s date of birth Other party's relationship Child is currently living with
(mmm/dd/yyyy)
to child

the following adult family member(s) sharing the residence with a protected person:
Complete only if the adult family member sharing the residence with another protected person needs to also be protected.
You may leave this section blank.
Full name Date of birth Relationship to the protected person(s)
(mmm/dd/yyyy)

Other (specify): Name: Date of birth

(full name of other person to be protected) (mmm/dd/yyyy)
Explain why you are applying for the other person.

The person(s) identified in the section above is/are referred to as the protected party/parties. The other party is the person
they need protection from.

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Form 12
SCH1-1 of 5
About the protection order –
This next set of questions will help the court understand what terms the protection order may need to include. You have already
identified who needs protection; these questions help to figure out what that protection might look like.
No go: In addition to not making any contact with the protected party, there may also be places you don’t want the other party to
be allowed to go.
Select all the options you want in the protection order. If you don’t want to restrict where the other person can go, you may leave
this section blank.
You don’t need to give specific names or addresses of these places now, but it is a good idea to bring that information with you to
court as the judge might ask for it.

No contact except: Sometimes it is impossible to stop all communication with the other party if you have children together or
you are still trying to sort out the details of your separation. If this applies to your situation, select all the options where you may
need to communicate with the other party. If you don’t need to communicate with them at all, you can leave this section blank.

Firearms prohibition: Indicate if you have concerns that the other party would harm or threaten the protected party using a
gun, explosive or another kind of firearm. If you do have concerns, explain to the court why. You do not need to use any special
wording. The key is to be clear about what you mean.

Surrender firearms: Indicate if you believe, or know, that the other party owns or has access to guns, explosives or another kind
of firearm. If you answered yes, explain why you believe or know this. You do not need to use any special wording. The key is to be
clear about what you mean.

Weapons prohibition: Indicate if you have concerns that the other party would harm or threaten the protected party using a
weapon that is not a gun or explosive. Weapons could include knives, martial arts weapons, sports equipment, or tools. If you do
have concerns, explain to the court why. You do not need to use any special wording. The key is to be clear about what you mean.

Remove weapons: Indicate if you believe, or know, that the other party owns or has access to a weapon that is not a gun or
explosive. Most people will have access to kitchen knives, sports equipment or tools – you do not need to answer yes if these
are the only weapons you believe the other party owns or has access to. If you do believe they own a weapon that is not a gun or
explosive and you answered yes, explain why you believe or know this. You do not need to use any special wording. The key is to
be clear about what you mean.

Residence: There are times when a protected party may be living with the person they need protection from. Is the protected
party in this application sharing a residence with the other party?
If the protected party or other party has just left a shared residence but does not have a new permanent place to live, you can still
answer yes to this question. A judge can make an order that they must leave the shared residence.

Remove person or belongings from residence: The court can order that the police help to remove the other party from a
shared residence and/or that the police help supervise the removal or collection of belongings from a residence. If a protected
party shares a residence with the other party, or has belongings at their residence, select the option that applies to the situation.
If police assistance isn’t necessary, you can leave this section blank.
ABOUT THE PROTECTION ORDER

3.
Complete only if applicable. You may leave this section blank.
I do not want the other party to be able to attend at, enter or be found at the following place(s):
Select all options that apply
residence
school
place of employment
child care facility
Other (specify):

4. Complete only if applicable. You may leave this section blank.

The protected party may need to communicate with the other party for the following reason(s):
Select all options that apply
consensual dispute resolution
parenting arrangements
ongoing court action
other (specify):

5. I have concerns the other party would cause harm with or threaten to use guns, explosives or another kind of firearm
Yes No
If yes, explain the reason(s) for your concerns.

6. I believe the other party owns or has access to guns, explosives or another kind of firearm Yes No
If yes, explain the reason(s) for your belief.

7. I have concerns the other party would cause harm with or threaten to use a weapon that is not a gun or explosive

Yes No
If yes, explain the reason(s) for your concerns.

8. I believe the other party owns a weapon that is not a gun or explosive Yes No
Examples of weapons someone might own include swords, hunting knives, and nunchucks.
If yes, explain the reason(s) for your belief.

9. The protected party currently shares a residence with the other party Yes No

10. Complete only if applicable. You may leave this section blank.
I believe police assistance may be required for the following purpose(s):
Select all options that apply
to remove the other party from the shared residence
to supervise the removal of the protected party’s personal belongings from the shared residence
to supervise the removal of the other party’s personal belongings from the shared residence
to supervise the removal of the child(ren)’s personal belongings from a residence
Other (specify):
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SCH1-2 of 5
Your story–
It is important for the court to understand the relationship between the protected party and the other party, as well as some of
the background that has brought you before the court to apply for a protection order. The next set of questions will help the court
understand a bit more about everyone involved.
Relationship between the parties: Describe how the protected party/parties and the other party are related or connected to
one another (for example, we were living together in a relationship and are both parents of the child).
You do not need to use any special wording. Describe the relationship or connection in your own words. If there is more than one
protected party, be clear about the relationship or connection of the other party to each of them.

Spouses/lived together: Indicate if the protected party, or the parent/guardian of the protected child, and the other party:
• are spouses
• were spouses
• live together in a marriage-like relationship with the other party, or
• lived together in a marriage-like relationship with the other party
If yes, please answer the questions about the relationship. Provide specific dates where possible. If you do not know a specific
date, provide the month and year.

Children: It is important for the court to know about each child in the relationship so that they may consider the implications of a
protection order and whether the child should also be included in the protection order.
If you have identified the child in paragraph 2 already as a protected party (someone you want to have protected by the order), or
you do not have a child, select the first option.
If the protected party or the other party have a child, but you are not applying for the child to be protected under the protection
order, select the second option and complete the required information.

Existing written agreements or court orders: The court needs to know if there were any agreements or court orders made in
the past that involve family law matters. This is so they can consider if the agreement or order is important to what you are asking
the court to help with now. This includes:
• any agreements between you and the other party
• any court orders, in this court or any other court

About my family: If there is any information about your cultural, linguistic, religious and spiritual upbringing and heritage of your
family, including if the child is an Indigenous child, that you would like to share with the court as part of your application, you may
do so here. You do not need to complete this information.
YOUR STORY
Relationship between parties
11. The protected party and the other party are:
Explain how the protected party/parties and the other party are related for the purposes of the application.

If the protection order is only for the protection of a child(ren), please answer the following question for the parents or guardians of the
child(ren).

12. The protected party is or has been spouses, or lives or has lived together in a marriage-like relationship, with the other party
Specify which protected adult if there is more than one
(name of party)
Yes No
If yes, please complete all options below that apply to the parties.
Date on which the parties began to live together in a marriage-like relationship:
(mmm/dd/yyyy)
Date of marriage:
(mmm/dd/yyyy)

Are the protected party and the other party currently separated Yes No Unknown
Spouses may be separated despite continuing to live in the same residence
If yes, the parties separated on
(mmm/dd/yyyy)

Children
13. Select whichever option is correct and complete the required information.
The protected party and the other party are a parent, step-parent or guardian only to the child(ren), if any, identified in
paragraph 2 of this affidavit.
The protected party and the other party are a parent, step-parent or guardian to the following child(ren) who is/are not identified
in paragraph 2 of this affidavit:

Child's full name Child's date Protected party's Other party's Child is currently living
of birth relationship to relationship to child with
(mmm/dd/yyyy)
child

14. Complete only if the protected party and the other party are a parent, step-parent or guardian.
There are existing written agreements or court orders about the children concerning parenting arrangements, child support, contact
with a child, or guardianship Yes No
If yes, attach a copy of the agreement(s) or order(s) to this affidavit.

About my family
15. You may choose to complete this section or leave this section blank.
I would like to share the following information with the court about the cultural, linguistic, religious and spiritual upbringing and
heritage of my family, including, if the child is an Indigenous child, the child's Indigenous identity:

PFA 720 10/2022

Form 12
SCH1-3 of 5
Mental health: Mental health conditions are disorders that affect your mood, thinking and behaviour. There are many different
mental health conditions including depression, anxiety disorders, bi-polar disorder and schizophrenia.
Indicate if you have concerns about the mental health of a protected party or the other party. If yes, explain your reasons for the
concerns and be sure to specify who those concerns are about. You do not need to use any special wording. The key is to be clear
about what you mean.

Risk factors: There are certain circumstances that may make a person or relationship more at-risk for family violence. The
circumstances may contribute to family violence but might not be the cause of the family violence. To better understand the
circumstances that may contribute to family violence in this case, indicate if you believe there are circumstances that may increase
the risk of family violence in the relationship. If yes, please describe the circumstances. A list is provided in the form of some
common circumstances that may contribute to family violence. You do not need to use any special wording when you are describing
the circumstances. The key is to be clear about what you mean.

Existing protection matters: The court needs to know if there are any agreements, plans or court orders with protective
conditions or terms between the parties or involving a child in this case. This includes:
• any family law protection order from Provincial Court, Supreme Court, or another jurisdiction
• any order, agreement or plan involving child protection services including a Protective Intervention Order or Supervision
Order under the Child, Family and Community Service Act
• any other order the court may need to know about that restricts or restrains contact, or protects one party and/or a child
from another party

Obeying a court order: A person does not always do what the court has told them they must do.
Do you know if the other party has ever failed to obey (breached) a court order? If you answered yes, explain why you believe or
know this. You do not need to use any special wording. The key is to be clear about what you mean.

Obeying a court order: The other party may never have been under a court order, or maybe this one would be different. Indicate if
you have concerns the other party may not obey a court order (do what the court tells them to do). If you do have concerns, explain
to the court why. You do not need to use any special wording. The key is to be clear about what you mean.

Reported to police: If you are a victim or witness of family violence, you may have reported safety concerns or an incident to the
police or RCMP. If you have reported your safety concerns or an incident to the police, describe what actions the police have taken
(for example they may have started a police report, talked to you and the other people involved, made an arrest). Whatever action
you know the police have taken, describe it here in your own words.

Reported to a social worker: In situations where there is reason to believe a child (under 19 years of age) is being abused,
neglected, sexually exploited, or is otherwise in need of protection, and a parent or guardian is unable or unwilling to protect the
child, the matter must be reported to a social worker at the Ministry of Children and Family Development.
For more information or to receive help making a report about a child or youth who needs protection, please call the Helpline for
Children at 1-800-663-9122 at any time of the day or night.
If you have reported your safety concerns or an incident to a social worker, describe what actions the social worker has taken (for
example they may have assessed the case and/or intervened). Whatever action you know the social worker has taken, describe it
here in your own words.
Other information
16. I have concerns about the mental health of the protected party and/or the other party Yes No
If yes, explain your concerns and the reason(s) for your concerns.

17. Are there circumstances that may increase the risk of family violence Yes No
If yes, describe the circumstances such as: substances abuse, employment or financial difficulties, relationship status, criminal
history, pregnancy, threats to you/another person/child/animal, stalking, forced sex, controlling behaviour, release from prison, stran-
gling/choking/biting, threats or attempts to commit suicide, cultural religious beliefs or any other circumstances.

18. There is an existing court order, agreement or plan protecting one of the parties, the child(ren), or restraining contact between the
parties, including a protection order, an order, agreement or plan involving child protection services, or a peace bond, restraining
order, bail conditions or other criminal order
Yes No
If yes, attach a copy of the orders, agreement(s), or plan(s) to your application.

19. Has the other party ever failed to obey a court order Yes No Unknown
If yes, describe the circumstances.

20. I have concerns the other party may not obey a court order Yes No
If yes, explain the reason(s) for your concerns.

21. I have reported my safety concerns to the police Yes No

If yes, describe what action they have taken. You will be asked to describe specific incidents that police attended in a later section.

22. I have reported my safety concerns to a social worker (Ministry of Children and Family Development) Yes No
If yes, describe what action they have taken.

PFA 720 10/2022

Form 12
SCH1-4 of 5
Other information –
Family violence: Family violence includes physical, sexual, and psychological or emotional abuse of a family member.
Psychological or emotional abuse includes intimidation, harassment, coercion, threats, financial abuse, stalking, and intentional
damage to property. In the case of a child, it includes witnessing or being exposed to family violence. Family violence does not
include self-defense.
Explain what family violence you fear. You can state the reason(s) why the protected party/parties are afraid of the other party
and think family violence may occur. You do not need to use any special wording. The key is to be clear about what you mean.

Safety concerns: If you have any concerns that you have not already described that have you worried for the safety of the
protected party/parties, you can use this space to add them. You do not need to use any special wording. The key is to be clear
about what you mean.

Incident history –
Describe any recent incidents of family violence against the protected party and any child(ren).
Start with the most recent incident continuing backwards as far as you think it is important for the court to know. You do not need
to use any special wording but it is important that you are clear and provide as much detail as possible, including:
• the date the incident occurred
• a description of the incident of family violence
• who was involved (including any witnesses or the police)
• the child(ren)’s involvement in the incident, if applicable
• any injuries or trauma from the incident
• any other detail about the incident you feel it is important for the court to know
Note: If there is a police report, medical report or doctor’s note, or any photographs related to the incident, you must talk about
them in this section, reference the document, state that it is attached as an exhibit and attach them as exhibits. Each exhibit gets
a letter assigned to it, starting with ‘A’ and continuing through the alphabet. For example, the police report attached as Exhibit A.
23. Is there any family violence you fear is likely to happen that you have not already described in this affidavit? Yes No
If yes, explain what type of family violence and the reason for your fear.

24. Do you have any concerns for the safety of the protected party/parties that you have not already described in this affidavit
Yes No
If yes, explain the concerns and the reason for your concerns.

25. Describe any recent incidents of family violence against the protected party/parties and any child(ren).
Include:
• how the other party made the protected party and/or the child(ren) feel unsafe (describe examples of the other party’s behaviour that
made you afraid)
• a description of the incident(s) (write as much detail as possible)
• who was involved (include the police if they were involved at any time)
• who witnessed it
• any exposure the child or children have had to violence or abuse
• any injuries or trauma from the incident
• any doctor’s notes, police reports or photos (you must refer to them here as exhibits and make copies of them for the court)

Sworn or affirmed before me

at , British Columbia
city

on
date

A Commissioner for taking Affidavits in British Columbia Signature

[print name or affix stamp of commissioner]

PFA 720 10/2022

Form 12
SCH1-5 of 5
CHANGE AN EXISTING PROTECTION ORDER
You need to complete this schedule if you are applying to change an existing protection order, including adding or removing a term
of the protection order, changing an existing term in the protection order, or changing when the protection order will expire.
If your application to change an existing protection order is granted by the court, they will cancel the existing protection order and
make a new one using all the same terms that were in the previous order but with the changes made.

Existing order –
The court needs to have a copy of the existing protection order. Attach the copy to your application and indicate the date the
protection order was made in the field provided.

Court appearance –
A protection order can be made without a party being present if they were served and didn’t come to court, or if the court decided
the order could be made without notice to the party.
Indicate if you were in court when the protection order was made. If you were not in court, explain why you weren’t there. You do not
need to use any special wording. The key is to be clear about what you mean.

Party –
Any party can apply to change an existing protection order. Let the court know what your role is in respect to the protection order.
If you are both the protected party or person who the protection order is against AND the parent or guardian of a protected party,
select both options that apply.

Changes to the protection order –

Explain what changes to the protection order you are asking the court to make. Try to be clear about what part of the existing order
you want to keep and what may need to be changed. You do not need to use any special wording. The key is to be clear about what
you mean.

The facts –
What are the facts that support what you are asking the court to order?
Give a summary of the facts including why you want the court to change the order.
You do not need to use any special wording. The key is to be clear about what you mean and why you are asking the court to
change the order.
Talk to a lawyer if you need help figuring out what facts you need to present to the court to support your application.
A judge can make decisions based only on the information presented by the parties as evidence. Evidence is presented in writing
in an affidavit or as spoken evidence provided in court.
If you choose to, you can prepare an Affidavit - General Form 45. If you do not wish to prepare an affidavit, be prepared to give
evidence in court.
 Schedule 2 – Change an Existing Protection Order
This is Schedule 2 to the Application about a Protection Order

This schedule must be completed if you are applying to change an existing protection order.

1. I am attaching a copy of the existing protection order made on

(mmm/dd/yyyy)

2. Select only one of the options below

I was in court when the protection order was made.
I was not in court when the protection order was made because:
Explain why you were not in court when the protection order was made.

3. I am the:
Select all options that apply
protected party
parent or guardian of a protected party
person who the protection order is against

4. I am applying for the existing protection order to be changed as follows:

YOUR STORY

5. The facts on which this application is based are as follows:

Explain why the order needs to be changed and the facts you want the court to consider.

PFA 720 10/2022

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SCH2-1 of 1
TERMINATE AN EXISTING PROTECTION ORDER
You need to complete this schedule if you are applying to terminate (cancel) an existing protection order.

Existing order –
The court needs to have a copy of the existing protection order. Attach the copy to your application and indicate the date the
protection order was made in the field provided.

Court appearance –
A protection order can be made without a party being present if they were served and didn’t come to court, or if the court decided
the order could be made without notice to the party.
Indicate if you were in court when the protection order was made. If you were not in court, explain why you weren’t there. You do
not need to use any special wording. The key is to be clear about what you mean.

Party –
Any party can apply to terminate a protection order. Let the court know what your role is in respect to the protection order.
If you are both the protected party or person who the protection order is against AND the parent or guardian of a protected party,
select both options that apply.

The facts –
What are the facts that support what you are asking the court to order?
Give a summary of the facts including why the protection order should be terminated (cancelled).
You do not need to use any special wording. The key is to be clear about what you mean and why you are asking the court to
terminate the order.
Talk to a lawyer if you need help figuring out what facts you need to present to the court to support your application.
A judge can make decisions based only on the information presented by the parties as evidence. Evidence is presented in writing
in an affidavit or as spoken evidence provided in court.

If you choose to, you can prepare an Affidavit - General Form 45. If you do not wish to prepare an affidavit, be prepared to give
evidence in court.
 Schedule 3 – Terminate an Existing Protection Order
This is Schedule 3 to the Application about a Protection Order

This schedule must be completed if you are applying to terminate an existing protection order.

1. I am attaching a copy of the existing protection order made on that I am applying to have terminated.
(mmm/dd/yyyy)

2. Select only one of the options below

I was in court when the protection order was made.
I was not in court when the protection order was made because:
Explain why you were not in court when the protection order was made.

3. I am the:
Select all options that apply
protected party.
parent or guardian of a protected party
person who the protection order is against

YOUR STORY

4. The facts on which this application is based are as follows:

Describe why the order should be terminated and the facts you want the court to consider.

PFA 720 10/2022

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SCH3-1 of 1