Stat e of Ala b a m a Unified Judicial System Form C-90 (Page 1 of 4) 8/17 PETITION FOR ELDER ABUSE PROTECTION ORDER Court Case Number IN THE CIRCUIT COURT OF COUNTY, ALABAMA (Name of County) v. [Name of Plaintiff (victim)] [Name of Defendant (person to be restrained)] (Name of Plaintiff filing on behalf of victim) (Name of Victim) [Defendant222s Address (Business or Home)] (Defendant222s Social Security Number) (City) (State) (Zip Code) (Defendant's Date of Birth) YOU MUST PROVIDE COMPLETE AND TRUTHFUL INFORMATION. IF YOU DO NOT, THE COURT MAY DISMISS THIS CASE, AND YOU MAY BE SUBJECT TO BEING CHARGED WITH PERJURY FOR KNOWINGLY PROVIDING FALSE INFORMATION. I. ELIGIBLE PLAINTIFFS:(Note: The word, 223Plaintiff,224 as used in this form, describes the victim and/or the person filing on behalf of the victim): I am 60 years of age or older and am in need of protection from elder abuse. OR I am filing on behalf of a person 60 years of age or older, who is need of protection from elder abuse and lacks the physical or mental capacity to seek protection for himself or herself, and I am the person222s (check all that apply): court appointed guardian (include copy of the court order of appointment); court appointed conservator (include copy of the court order of appointment); court appointed temporary guardian (include copy of the court order of appointment); agent, co-agent, or successor agent appointed under the plaintiff222s validly executed power of attorney who acts within the authority of the power of attorney (include copy of the power of attorney); health care proxy appointed under the plaintiff222s validly executed Advance Directive for Health Care or similar document (include document); an interested person who has the authority to petition for protective placement or other protective services under Section 38-9-6, Ala. Code 1975 . I state that the following is true and correct: The Plaintiff is a resident of County/Parish in the State of . (Name of County/Parish) (Name of State) Are there any criminal charges against the Defendant because of abuse to the Plaintiff? YES NO If YES, the charges were brought in County/Parish, . (Name of County/Parish) (Name of State) (Note: If there are more civil or other cases with the Defendant or more criminal charges against the Defendant, please attach additional 8224 x 11224 sheets of paper, if necessary, stating the case number(s), County(ies)/Parish(es), and States(s) in which these cases are being handled). (Check one or more of the following boxes if the statement(s) apply/applies to the Plaintiff): The Plaintiff left his or her residence to avoid further abuse or threat of abuse, and the Plaintiff is temporarily located in County, Alabama. (Name of County) The Defendant lives in County/Parish, (Name of County/Parish) (Name of State) The elder abuse occurred in County, Alabama. (Name of County) I am requesting an elder abuse protection order; a change in a current protection order; an emergency order; a change in an emergency order. Sections 38-9F-1 to 38-9F-12, Ala. Code 1975 Original - Court Record Copy - Law Enforcement Copy - Plaintiff Copy - Defendant American LegalNet, Inc. www.FormsWorkFlow.com State of Alabama Unified Judicial System Form C-90 (Page 2 of 4) 8/17 PETITION FOR ELDER ABUSE PROTECTION ORDER Court Case Number II.To Get a Protection Order, the Defendant Must Have Done One or More of the Following (Check all that apply): Threatened to confine the Plaintiff Made the Plaintiff afraid that the Plaintiff would be seriously injured Injured the Plaintiff Made the Plaintiff have sex by force or threat of force Used force to exert control over the Plaintiff222s property Kidnapped the Plaintiff Threatened to injure/hurt the Plaintiff Trespassed on the Plaintiff222s property Stalked the Plaintiff Tortured or willfully abused the Plaintiff Set fire to the Plaintiff's house Stole from the Plaintiff Restrained the Plaintiff Recklessly engaged in conduct which risked serious injury to the Plaintiff Took away or deprived the Plaintiff of food, clothing or shelter Inflicted emotional or mental anguish on the Plaintiff Prevented Plaintiff from receiving mental or physical health care Other (please specify): III.Explain the Abuse That Has Happened Below (If Applicable) (Begin With the Most Recent Act. You May Add Additional 8224 x11224 Sheets of Paper, If Necessary): Date and place where the elder abuse occurred: . Describe how the Defendant hurt or threatened the Plaintiff or how the Plaintiff is in imminent danger of becoming a victim: . Describe how the Defendant stole from the Plaintiff: . I genuinely fear the Defendant will cause further abuse because: . IV.Legal Information (Check all that apply): There is a current restraining or protection order against the Defendant: YES; I don222t know; NO. If YES, the County and State where it was issued: County, (State). (Name of County) (Name of State) The Defendant has a current restraining or protection order against the Plaintiff: YES; No. If YES, the County and State where it was issued: County, (State). (Name of County) (Name of State) The Plaintiff has a court appointed guardian or conservator: YES; I don222t know; NO. If YES, the County and State where it was issued: County, (State). (Name of County) (Name of State) (Note: If there are more current restraining or protection orders against the Defendant or against the Plaintiff, please attach additional 8224 x 11224 sheets of paper, if necessary, stating the case number(s), County(ies)/Parish(es), and State(s) in which these Orders were issued). Original - Court Record Copy - Law Enforcement Copy - Plaintiff Copy - Defendant American LegalNet, Inc. www.FormsWorkFlow.com State of Alabama Unified Judicial System Form C-90 (Page 3 of 4) 8/17 PETITION FOR ELDER ABUSE PROTECTION ORDER Court Case Number V.Residence THE DEFENDANT MAY BE REQUIRED TO MOVE FROM THE PLAINTIFF222S RESIDENCE IF THE RESIDENCE IS IN THE SOLE NAME OF THE PLAINTIFF, IF IT IS JOINTLY OWNED OR RENTED BY THE PLAINTIFF AND THE DEFENDANT. The place where the Plaintiff lives is: Owned by: the Plaintiff; or the Defendant; or both the Plaintiff and the Defendant. Rented by: VI.Emergency Relief Requested (Please Check the Boxes To Show What is Requested): The Plaintiff is at risk of imminent potential harm, and I am asking the Court for the following for myself or the person(s) for whom I am applying: (1)Enjoin the Defendant from threatening to commit or committing acts of elder abuse, as defined in the Elder Abuse Protection Order and Enforcement Act,against the: Plaintiff; and/or any designated person, to-wit: . (Name of Person) (2) Restrain and enjoin the Defendant from: Harassing; Stalking; Annoying; Telephoning; Contacting*; Communicating with: the Plaintiff; OR Threatening or engaging in conduct that would place the following in reasonable fear of bodily injury: he Plaintiff; and/or ny designated person, to wit: . (Name of Person) * "Contacting" may include, but is not limited to, communicating with the victim verbally or in any written form, either in person, telephonically, electronically, or in any other manner, either directly or indirectly through a third person. (3) Order the Defendant to stay away from: the Plaintiff222s residence; place of employment; and/or any specified place frequented by the Plaintiff t the Defendant has no legitimate reason to frequent, to-wit: . (Place) (4)Remove and exclude the Defendant from the residence of the Plaintiff, regardless of ownership of the residence. (5) Order possession and use of an: automobile and/or other essential personal effects regardless of ownership; and direct the appropriate law enforcement officer to accompany the Plaintiff to the residence of the Plaintiff or to other specified locations as necessary to protect the Plaintiff from abuse. (6) Prohibit the Defendant from: transferring; concealing; encumbering; or otherwise disposing of specified property mutually owned or leased by the parties or in which the Plaintiff had an ownership interest within the last 12 months, to-wit:, (Please describe property). (7) Prohibit the Defendant from transferring the funds, benefits, p