Petition: 1 of 5 Pages 0007 3501 CCG N800 A-20M-2/28/05 ( ) IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS People ex rel. _____________________________________________ ______________________________________________ on behalf of Case No. _____________________________________ self and/or on behalf of ____________________________ Independent Proceeding Other Civil Proceeding ____________________________________________________ (specify) Petitioner v. ______________________________ Criminal Proceeding Juvenile Proceeding ____________________________________________________ Respondent PETITION FOR ORDER OF PROTECTION (Fill in lines and check boxes as applicable) Now comes the Petitioner ___________________________________________________ on his/her own behalf or on behalf of ____________________________________________________, a minor child, or on behalf of ______________________ ______________________________________________, an adult who cannot file a petition because of age, health, disability or inaccessibility on his/her own behalf, pursuant to the Illinois Domestic Violence Act (IDVA), and moves this Honorable Court to issue an Order of Protection in this cause and in support thereof states as follows: ALLEGATIONS THIS COURT HAS JURISDICTION OF THE SUBJECT MATTER AND OVER ALL NECESSARY PERSONS, WITH APPROPRIATE VENUE, BECAUSE: A. Petitioner resides at ___________________________________________________________________________________, (Street Address, City) in the County of _______________________ State of ____________________; OR Petitioner resides at ___________________________________________________________________________________, (Street Address, City) in the County of _______________________ State of ___________________; and __________________________________, the person on whose behalf this Petition is brought, resides at _____________________________________________________, (Street Address, City) in the County of _______________________ State of ____________________; OR Petitioner's address is omitted pursuant to statute. [Alternative address for notice of any motion is ______________________________ ______________________________________________________________________________________________________ .] B. Respondent resides at ____________________________________________________________________________________, (Street Address, City) in the County of _______________________ State of _____________________________. C. Respondent stands in relationship to the Petitioner or alleged abused person/as: Spouse; Former spouse; Parent; Child; Having or allegedly having a child in common; Stepchild; Sharing or formerly sharing a common dwelling; Having or having had a dating or engagement relationship; Other person related by blood or marriage. Sharing a blood relationship through a child; Personal assistant to person with disabilities or a person who has responsibility for a high-risk adult with disabilities; DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Case No. ________________________________ Petition: 2 of 5 Pages D. CCG N800 B-20M-2/28/05 ( ) There is no other pending court action involving the parties OR there is another pending court action involving the parties in ________________________________________________ Court, County of _______________________ State of _______________________ known as Case No. ________________________. E. _______________________________________________________________ _________________________________________________________________________________________________ ________________________________________________________________________________________________. As referred to herein, "the minor child/ren" are The Court has jurisdiction over the minor child/ren because: 1. the State of Illinois a. is the home state (as defined in the Illinois Uniform Child Custody Jurisdiction Act) of the child/ren at the time of the commencement of this proceeding, or b. had been the child/ren's home state within 6 months before commencement of the proceeding and the child is absent from this State because of his/her removal or retention by a person claiming his/her custody or for other reasons, and parent or person acting as parent continues to live in this state; OR 2. it is in the best interest of the child that a court of this State assume jurisdiction because the child and his/her parents, or the child and at least one contestant, have significant connection with this State, and there is available in this State substantial evidence concerning the child's present or future care, protection, training and personal relationships; 3. the child is physically present in this State and OR a. the child has been abandoned, or b. it is necessary in an emergency to protect the child because s/he has been subjected to or threatened with mistreatment or abuse or is otherwise neglected or dependent; OR 4. F. it appears that no other state would have jurisdiction under prerequisites substantially in accordance with paragraphs 1, 2 or 3 or another state has declined to exercise jurisdiction on the grounds that this State is the more appropriate forum to determine the custody of the child, and it is in the best interest of the child that this Court assume jurisdiction. No "father and child relationship" (pursuant to the Illinois Parentage Act of 1984) has been established with the following child/ren: ___________________________________________________________________________________________________. G. The primary caretaker of the minor child/ren is or has been _______________________________________________________. H. Venue in civil proceedings is appropriate because: Petitioner resides in the County of Cook, State of Illinois; OR Respondent resides in the County of Cook, State of Illinois; OR the alleged abuse occurred in the County of Cook, State of Illinois; OR the Petitioner is temporarily located in the County of Cook, State of Illinois, to avoid further abuse, and could not obtain safe, accessible, and adequate temporary housing in the county of his/her residence. PETITIONER ALLEGES AS TO RESPONDENT THAT: I. J. the following individuals are alleged to be persons who need to be protected from abuse by Respondent: _________________________ ___________________________________________________________________________________________________. Respondent has acted in the following manner towards the Petitioner: [State details of incident(s) of abuse (including time and place), as well as effects of incident(s) on Petitioner.] ___________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Effect(s):______________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Incident(s): DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Case No. ________________________________ Petition: 3 of 5 Pages K. CCG N800 C-20M-2/28/05 ( ) Petitioner should be granted exclusive possession of the residence, the special venue rules of sec. 209(b) of IDVA (applicable only in civil proceedings) having been met, because: Petitioner has a right to occupancy and Respondent has no right to occupancy OR both parties have a right to occupancy; and, considering the risk of further abuse by Respondent interfering with the Petitioner's safe and peaceful occupancy, the balance of hardships favors the Petitioner because of the following relevant factors: Availability, accessibility, cost, safety, adequacy, location and other characteristics of alternative housing for each party and any minors or other dependents; and/or Effect on each party's employment; and/or Other factors, as follows: ___________________________________________________________________________ ___________________________________________________________________________________________. L. Respondent should be ordered to stay away from Petitioner and the protected persons. Respondent should be prohibited from entering or remaining present at Petitioner's school, place of employment or (specify) __________________________________________________________________________________________ because: Respondent has no right to enter/remain present at such place(s); OR The balance of hardships favors the Petitioner in prohibiting the Respondent from entering or remaining at such place(s). M. N. The likelihood of future abuse would be minimized by appropriate counseling. Petitioner should be granted physical care of the minor child/ren or granted other appropriate relief because there exists a danger that the minor child/ren will be: abused or neglected; and/or separated in an unwarranted manner from the child/ren's primary caretaker; and/or unprotected as to his/her/their well-being. O. Petitioner should be granted temporary legal custody of the minor child/ren. P. The Respondent's visitation with the minor child/ren should be restricted or denied because the Respondent has or is likely to: abuse or endanger the minor child/ren during visitation; and/or use visitation as an opportunity to abuse or harass Petitioner or Petitioner's family or household members; and/or improperly conceal or detain the minor child/ren; and/or otherwise act in a manner that is not in the best interest of the minor child/ren. Q. There exists a danger that the minor child/ren will be removed from this jurisdiction or concealed within the State. R. Respondent has knowledge of the whereabouts of, or access to, the minor child/ren. S. Petitioner should be granted exclusive possession of the following items of personal property: ______________________________________________________________________________________________ ________________________________________________________________________________________________, because: Petitioner, but not Respondent, owns such property; OR sharing the property creates a further risk of abuse or is impractical; the balance of hardships favors temporary possession by Petitioner; and Petitioner and Respondent own the property jointly, or the property is alleged to be marital property and a proceeding has been filed under the IMDMA. T. An order should be granted protecting the following items of personal property: _________________________________________________________________________________________________ ________________________________________________________________________________________________, because: Petitioner, but not Respondent, owns such property; OR the balance of hardships favors Petitioner, and Petitioner and Respondent own the property jointly, or the property is alleged to be marital property and a proceeding has been filed under the IMDMA. U. Respondent has a legal obligation to support Petitioner and/or the minor child/ren, and Respondent is able to provide such support. V. As a direct result of the above described abuse, Petitioner has suffered certain losses, incurred certain expenses, and/or has been provided temporary shelter/counseling services, as follows: _________________________________________________________________________________________________ _____________________________________________________________________________________________ _______________________________________________________________________________________________. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Case No. ____________________________ Petition: 4 of 5 Pages W(1). W(2). X. CCG N800 D-20M-2/28/05 ( ) There is a threat to the safety and well-being of Petitioner's family or household when Respondent enters or remains on the premises while under the influence of alcohol or drugs. Respondent should be ordered to surrender any and all firearms to the local law enforcement agency. If Respondent is a law enforcement officer, any and all firearms must be surrendered to Respondent's employer. Respondent should be denied access to school or other records of the minor child/ren because: Respondent is or will be prohibited from having contact with the minor child/ren; or Petitioner's address is omitted pursuant to statute; or it is necessary to prevent abuse or wrongful removal or concealment of the minor child/ren. Allegations for other injunctive relief: Y. _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Z. Disclosure of Petitioner's address would risk further abuse to her/him or to another protected person, or such disclosure would reveal the confidential location of a shelter for domestic violence victims. Additional Allegations for Emergency Orders Only (i) For requested remedies 1, 3, 5, 7, 8, 9, 11, 14, 15, and 17, the harm which that remedy is intended to prevent would be likely to occur if Respondent were given any prior notice, or greater notice than was actually given of Petitioner's efforts to obtain judicial relief. (ii) For requested remedy 2, the immediate danger of further abuse of Petitioner by Respondent if Petitioner chose or had chosen to remain in the household while Respondent was given any prior notice or greater notice than was actually given, outweighs the hardship to Respondent of an emergency order granting Petitioner exclusive possession of the residence or household. (iii) For requested remedy 10, improper disposition of the personal property would be likely to occur if Respondent were given any prior notice or greater notice than was actually given of Petitioner's effort to obtain judicial relief, or that Petitioner has an immediate and pressing need for possession of that property. REMEDIES REQUESTED PETITIONER REQUESTS THAT THE COURT FIND THAT THE FOLLOWING ARE PROTECTED PERSONS: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ WHEREFORE, PETITIONER REQUESTS THE ENTRY OF AN ORDER OF PROTECTION SETTING FORTH THE FOLLOWING REMEDIES: 1. With respect to Petitioner and other Protected Persons, Respondent should be prohibited from committing the following: Physical abuse; Harassment; Interference with personal liberty; Intimidation of a dependent; Exploitation; Stalking. Willful deprivation; Neglect; 2. Petitioner should be granted exclusive possession of the residence and Respondent should be prohibited from entering or remaining at such premises: (Address) 3. ___________________________________________________________________________________________. a. Respondent should be ordered to stay away from Petitioner and other protected persons; and/or ________________________________________________ _____________________________________________________________ while any Protected Person is present; and/or Respondent should be allowed access to the residence on (date) _________________ at (time) _____________ in the presense of (name) _________________________________________ to remove items of clothing, personal adorments, medications used exclusively by the Respondent and other items, as follows: ____________________________________________________. b. Respondent should be prohibited from entering or remaining at c. 4. Respondent should be ordered to undergo counseling for a period of time to be determined by this court. (Not available in Emergency Order) 5. a. Petitioner should be granted physical care and possession of the minor child/ren; b. Respondent should be ordered to: and/or return the minor child/ren _________________________________________________________ to the physical care of _____________________________________________________________________________________; and/or not remove the minor child/ren _________________________________________________________________ from the physical care of Petitioner or ____________________________________________________________________. 6. Petitioner should be granted temporary legal custody of the minor child/ren _______________________________________________. (Not available in Emergency Order) DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Case No. ________________________________ Petition: 5 of 5 Pages 7. CCG N800 E-20M-2/28/05 ( ) a. Respondent should be awarded visitation rights on the following dates and times or under the following conditions or parameters: (No order shall merely refer to the term "reasonable visitation".) _____________________________________________________________________________________ ___________________________________________________________________________________________. b. Respondent's visitation should be restricted as follows: _____________________________________________________________________________________ ___________________________________________________________________________________________. 8. 9. 10. c. Respondent's visitation should be denied. Respondent should be prohibited from removing the minor child/ren from Illinois or concealing them within Illinois. Respondent should be ordered to appear in this Court with/without the child/ren on a date certain. Petitioner should be granted exclusive temporary possession of the following personal property and the Respondent should be ordered to deliver to Petitioner said property that is in Respondent's possession or control, to wit: __________________________________________________________________________________________________ ________________________________________________________________________________________________. 11. Respondent should be ordered not to take, encumber, conceal, damage or otherwise dispose of any of the following real or personal property, to wit: _______________________________________________________________________________________________ 12. ________________________________________________________________________________________________. Respondent should be ordered to pay temporary support for Petitioner and/or the minor child/ren of the parties as follows $ _____________ per_________________, starting __________________________ payable through the Clerk of the Circuit Court, or directly to Petitioner. (Not available in Emergency Order) 13. Respondent should be ordered to pay $ ____________ respecting losses and expenses within the scope of Sec. 214(b)(13) of the IDVA to __________________________ on or before ________________________. (Not available in Emergency Order) 14. Respondent should be prohibited from entering or remaining at the household or residence located at ____________________________ __________________________________________________________________________________________ while under the influence of alcohol or drugs and so constituting a threat to the safety and well-being of any Protected Person. 14.5. Respondent must be ordered to surrender any and all firearms to the local law enforcement agency (i.e., police department). If the Respondent is a law enforcement officer, any and all firearms must be surrendered to Respondent's employer. (All surrendered firearms shall remain confiscated for a period not to exceed two (2) years.) 15. Respondent should be denied access to school or any other records of the minor child/ren and prohibited from inspecting, obtaining or attempting to inspect or obtain such records. 16. Respondent should be ordered to pay $ ______________ to the following shelter ________________________________________ 17. on or before _____________________________. (Not available in Emergency Order) Respondent should be further enjoined as follows: ______________________________________________________________________________________________ ________________________________________________________________________________________________ ______________________________________________________________________________________________ ________________________________________________________________________________________________ _____________________________________________ ___________________________________________ Signature of Petitioner Signature of Attorney or State's Attorney UNDER THE PENALTIES OF PERJURY AND AS PROVIDED BY LAW PURSUANT TO SECTION 1-109 OF THE CODE OF CIVIL PROCEDURE, THE UNDERSIGNED CERTIFIES THAT THE STATEMENTS SET FORTH IN THIS INSTRUMENT ARE TRUE AND CORRECT, EXCEPT AS TO MATTERS STATED TO BE ON INFORMATION AND BELIEF AND AS TO SUCH MATTERS THE UNDERSIGNED BELIEVES THE SAME TO BE TRUE. Dated: ______________________________, ___________ ___________________________________________ Signature of Petitioner Atty. No.: _________________ Attorney (or Pro Se Petitioner): Name: _____________________________________________________ Address: __________________________________________________ City/State/Zip: _______________________________________________ Telephone: _________________________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Case No. ________________________________