Form FVIO4
APPLICATION TO EXTEND, VARY OR REVOKE
AN INTERVENTION ORDER
Family Violence Protection Act 2008, Sections 100-113
Magistrates’ Court
of Victoria
In the Magistrates’ Court at
Case No
APPLICANT
Address
Contact Number
PROTECTED PERSON
Address
Contact Number
Do you wish to disclose your address?
Yes
No
RESPONDENT
Address
Contact Number
ADDITIONAL APPLICANT
Address
ADDITIONAL RESPONDENT
Address
I SEEK TO:
extend the order
vary the order
revoke the order
Please briefly state the reasons for the
application
FVIO4 September 2011
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This application is made by:
Applicant for original intervention order
Protected person
Parent of protected person
Respondent
Additional protected person
Additional Respondent
Police officer (not applicant in original proceeding)
If you are the respondent, you must
demonstrate a change in circumstances
since the intervention order was made.
What do you say about any change of
circumstances?
If you wish to vary the order, what
changes do you seek?
If you wish to extend the order, please
specify the duration of the extension
sought.
Date of making of the family violence
intervention order
Are there any other persons who have
become family members of the
respondent since the family violence
intervention order was made?
Yes
No
Name:
Male
Female
Date of Birth
Relationship to Respondent
Name:
Male
Female
Date of Birth
Relationship to Respondent
Name:
Male
Female
Date of Birth
Relationship to Respondent
Name:
Male
Female
Date of Birth
Relationship to Respondent
FVIO4 September 2011
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Details of any relevant Family Law Act
order or child protection order, or any
current application for a relevant Family
Law Act order or child protection order.
SIGNATURE OF APPLICANT
Signature of
Applicant
X
Date
For further information contact your local Magistrates’ Court of Victoria or visit www.magistratescourt.vic.gov.au
COURT USE ONLY (Leave & Consent Requirements)
If the protected person is not the applicant, does the protected
person consent to the variation or extension of the family
violence intervention order?
Yes
No
If the protected person is a child, does a parent of the child
consent to the variation or extension of the family violence
intervention order?
Yes
No
If the protected person has a guardian, does the guardian
consent to the variation or extension of the family violence
intervention order?
Yes
No
Leave of the Court required where respondent to original
proceeding seeks to make application (s 109 FVPA Act):
Yes
No
Leave of the Court required where protected person is a child
aged 14 years or more and seeks to make application (s 108
FVPA Act):
Yes
No
FVIO4 September 2011
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