Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinoiscookcountyclerkofcourt.orgPage 1 of 5 � en-USen-USPetitioneren-USv. en-USRespondent Case No. � en-US en-US Name: � en-US Address: � � Street Address � City � State � Zip Family member of the Respondent. The checked boxes show my relationship to the en-USRespondent: � Spouse � � Parent � � Child � � Step-child Related by blood � � Related by present marriage � � Live with Respondent en-USOR � � Badge No.: � Municipality: � en-US Location: � � en-US Name: � en-US Address:� � Street Address � City � State � Zip en-US Resident of Illinois � Respondent resides in � en-US County, Illinoisen-USOR Respondent is a non-resident with limited contact with Illinois. Are you aware of any court case involving the Respondent? � � Yes � � No Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinoiscookcountyclerkofcourt.orgPage 2 of 5en-USIf yes, please check the boxes and give as much information as you know about each case: � en-US I request an Emergency Firearms Restraining Order. en-USen-USen-USen-USen-USen-USen-USen-US I request a Six Month Firearms Restraining Order. en-USen-USen-USen-USen-USen-USen-USen-US � � � � � � � � � � � � � � en-USen-USen-US en-USen-USen-USen-USen-USen-US Domestic Violence Order en-USof Protection Divorce, Parentage, Child en-USCustody Stalking No Contact Order Workplace Violence Civil No Contact Order Child or Elder Abuse Involuntary commitment � Criminal Other (please specify) Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinoiscookcountyclerkofcourt.orgPage 3 of 5 � en-USen-USThe following facts cause me to believe that the Respondent is a danger to him/herself or others.en-USen-US I am informed, and on that basis believe, that Respondent poses an immediate and present en-USdanger of causing personal injury to him/herself or others.en-US � � � � � � � � � � � � � � en-USor another person.en-US � � � � � � � � � Respondent has a history of using, attempting to use, or threatening to use physical force en-USagainst another person. Respondent has a prior felony arrest. Respondent has abused controlled substances and/or alcohol Respondent has recently threatened violence or committed violence toward him/herself, or en-USanother person. Respondent has violated an Emergency Order of Protection Respondent has a pattern of violent acts or violent threats toward him/herself and/or toward en-USsomeone else. Respondent has a history of mental illness or has previously been treated for mental illness. en-USen-USen-USen-US I am informed, and on that basis believe, that Respondent currently possesses or controls Dorothy Brown, Clerk of the Circuit Court of Cook County, Illinoiscookcountyclerkofcourt.orgPage 4 of 5en-USen-US223Intimate partner224 means a spouse, former spouse, a person who has or says they have a child with en-USthe Respondent, or a person who dates or used to date or be engaged to the Respondent. � en-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USHandgunen-USHandgunen-USHandgunen-USHandgunen-US1.en-US � Custody/Control � Purchased � Possesses � Received en-US Date: � en-US Time: � en-USen-US2.en-US � Custody/Control � Purchased � Possesses � Received en-US Date: � en-US Time: � en-USen-USen-USen-USen-USen-US1.en-US � Custody/Control � Purchased � Possesses � Received en-US Date: � en-US Time: � en-USen-US2.en-US � Custody/Control � Purchased � Possesses � Received en-US Date: � en-US Time: � en-US � � � � en-US1.en-US � Custody/Control � Purchased � Possesses � Received en-US Date: � en-US Time: � en-USen-US2.en-US � Custody/Control � Purchased � Possesses � Received en-US Date: � en-US Time: � en-USDorothy Brown, Clerk of the Circuit Court of Cook County, Illinoiscookcountyclerkofcourt.orgPage 5 of 5en-US en-USI have no information to believe that Respondent poses an immediate and present danger tointimate partneren-USAND/OR has made threats to an intimate partner. en-USOR Respondent IS an immediate and present danger to or has made threats to an intimate partner. � � � � � � � � � � � � � � en-USFirearms Restraining Order. en-USen-USen-USOR � � � � � � � � � � � � � � en-USasking for a Firearms Restraining Order. en-USen-US � � � � � � � � � � � � � � � en-USdomestic violence and/or stalking resources.en-USen-USen-USen-USen-US � Date: � � en-US � � en-USPrepared by: If Attorney, ARDC. No.: � en-US Name: � en-US Address: � en-US City: � � State: � � Zip: � en-US Phone: � � Fax: � en-US Primary Email: � en-US