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o CIRCUIT COURT o DISTRICT COURT OF MARYLAND FOR ............................................ City/County
Located at............................................................................................Case No. .........................................
Court Address

......................................................................................
Name of Petitioner on Original Court Order Home: Work:

vs.

......................................................................................
Name of Respondent on Original Court Order Home: Work:

......................................................................................
Street Address, Apt. No.

......................................................................................
Street Address, Apt. No.

......................................................................................
City, State, Zip Code Telephone

......................................................................................
City, State, Zip Code Telephone

PETITION TO MODIFY/RESCIND PROTECTIVE ORDER
I,............................................................................, the o Respondent, o Petitioner, o Person Eligible For Relief in the above entitled case, ask this Court to:

o modify the Protective Order in this case dated .............................................as follows:
............................................................................................................................................................................ ............................................................................................................................................................................ ............................................................................................................................................................................

o rescind the Protective Order in this case dated ..............................................................................................
My reasons are:........................................................................................................................................................... ........................................................................................................................................................................................... ........................................................................................................................................................................................... ........................................................................................................................................................................................... ......................................................................................
Date

......................................................................................
Signature

..............................................................................
Street Address (unless confidential) Home: Telephone Work: .............................................................................. City, State, Zip Code

CERTIFICATE OF SERVICE
I hereby certify that on the................. day of ................................, ................ , I mailed a copy of this Petition to:
Month Year

..........................................................................................................................................................................
Name and Address Name and Address

..........................................................................................................................................................................
......................................................................................
Date

......................................................................................
Signature

ORDER OF COURT
It is this................ day of........................................, ..................., ORDERED that:
Month Year

o this matter be scheduled for a hearing. o the Petition is DENIED because....................................................................................................................
............................................................................................................................................................................

..............................................................................
Judge

CC-DC/DV 6 (Rev. 2/2003)

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