IN THE CIRCUIT COURT OF THE SIXTEENTH JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS CLERKS USE ONLY Removal Out of County Service in Court PETITIONER Case No. Order of Protection Emergency Interim Plenary (Final) *Mandatory fields Present for hearing. First M. Petitioner's Address/Alternative Address: RESPONDENT Last Present for hearing. *First *M. *Last Relationship to Petitioner: Respondent's Address: File Stamp (Home - City, State and County) (Other - City, State and County) *SEX *RACE RESPONDENT IDENTIFIERS *DOB *HT. *WT. *EYES *HAIR SSN DL NUMBER, STATE & EXPIR. THE COURT HAVING JURISDICTION OF THE SUBJECT MATTER, IT IS HEREBY ORDERED This Order was issued on Date This Order will be in effect Until: Time Date A Plenary hearing will be held on Time at .m in room at the DeKalb County Courthouse, 133 W. State St., Sycamore, IL 60178 The following person(s) is/are protected by this Order As referred to herein, "the minor child/ren of the parties " are (full name, D.O.B) Other minor child/ren that reside in household (full name, D.O.B) 1. With respect to All Protected Persons, the Respondent is prohibited from committing the following: harassment, interference with personal liberty, physical abuse, intimidation of a dependent, willful deprivation, neglect or exploitation as defined in this act, and stalking as defined in section 12-7.3 of the Criminal Code of 1992. 2. Petitioner is granted exclusive possession of the residence and Respondent shall not enter or remain in the household of premises located at: (This remedy does not affect title to property.) 3. a. Respondent is ordered to stay away from the Petitioner and other protected persons; and/or b. Respondent is prohibited from entering or remaining while Petitioner and/or protected person(s) is/are present at: Their place of employment at: P1-OP-02 (03/06) Page 1 of 5 White - Clerk Green - Petitioner Yellow - Sheriff Pink - Respondent Gold - Attorney/SAO American LegalNet, Inc. www.USCourtForms.com DEFINITIONS PURSUANT TO THE ILLINOIS DOMESTIC VIOLENCE ACT 750 ILCS 60/101 et seq. 1. "Petitioner" may mean not only any named petitioner for the order of protection and any named victim of abuse on whose behalf the petition is brought, but also any other person protected by this Act. 2. "Abuse" means physical abuse, harrassment, intimidation of a dependent, interference with personal liberty or willful deprivation, but does not include reasonable direction of a minor child by a parent or person in loco parentis. 3. "Physical abuse" includes sexual abuse and means any of the following: (a) knowing or reckless use of physical force, confinement or restraint; (b) knowing, repeated and unnecessary sleep deprivation; or (c) knowing or reckless conduct which creates an immediate risk of physical harm. 4. "Harassment" means knowing conduct which is not necessary to accomplish a purpose that is reasonable under the circumstances; would cause a reasonable person emotional distress; and does cause emotional distress to the petitioner. Unless the presumption is rebutted by a preponderance of the evidence, the following types of conduct shall be presumed to cause emotional distress: (a) creating a disturbance at petitioner's place of employment or school: (b) repeatedly telephoning petitioner's place of employment, home, or residence; (c) repeatedly following petitioner about in a public place or places; (d) repeatedly keeping petitioner under surveillance by remaining present outside his or her home, school, place of employment, vehicle or other place occupied by petitioner or by peering in petitioner's windows; (e) improperly concealing a minor child from petitioner, repeatedly threatening to improperly remove a minor child of petitioner's from the jurisdiction or from the physical care of petitioner, repeatedly threatening to conceal a minor child from petitioner, or making a single such threat following an actual or attempted improper removal or concealment, unless respondent was fleeing an incident or pattern of domestic violence; (f) threatening physical force, confinement or restraint on one or more occasions. 5. "Interference with personal liberty" means committing or threatening physical abuse, harassment, intimidation or willful deprivation so as to compel another to engage in conduct from which she or he has a right to abstain or to refrain from conduct in which she or he has a right to engage. 6. "Willfull deprivation" means willfully denying a person who because of age, health or disability requires medication, medicare care, shelter, accessible shelter or services, food, therapeutic device, or other physical assistance, and thereby exposing that person to the risk of physical, mental or emotional harm, except with regard to medical care or treatment when the dependent person has expressed an intent to forgo such medical care or treatment. This paragraph does not create any new affirmative duty to provide support to dependent persons. 7. "Intimidation of dependent" means subjecting a person who is dependent because of age, health or disability to participation in or the witnessing of: physical force against another or physical confinement or restraint of another which constitutes physical abuse as defined in this Act, regardless of whether the abused person is a family or household member. 8. " Exploitation" means the illegal, including tortious, use of a high-risk adult with disabilities or of the assets or resources of a high-risk adult with disabilities. Exploitation includes, but is not limited to, the misappropriatation of assets or resources of a high-risk adult with disabilities by undue influence, by breach of fiduciary relationship, by fraud, deception, or extortion, or the use of such assets or resources in a manner contrary to law. 9. "Neglect" means the failure to exercise that degree of care toward a high-risk adult with disabilities which a reasonable person would exercise under the circumstances and includes but is not limited to: (a) the failure to take reasonable steps to protect a high-risk adult with disabilities from acts of abuse; (b) the repeated, careless imposition of unreasonable confinement; (c) the failure to provide food, shelter, clothing, and personal hygiene to a high-risk adult with disabilites who require such assistance; (d) the failure to provide medical and rehabilitative care for the physical and mental health needs of a high-risk adult with disabilities; or (e) the failure to protect a high-risk adult with disabilities from health and safety hazards. 10. "Stay Away" means respondent to refrain from both physical presence and nonphysical contact with the petitioner whether direct, indirect (including, but not limited to, telephone calls, mail, email, faxes, and written notes), or through third parties. P1-OP-02 (03/06) Page 2 of 5 White - Clerk Green - Petitioner Yellow - Sheriff Pink - Respondent Gold - Attorney/SAO American LegalNet, Inc. www.USCourtForms.com Order of Protection Continued Case No. Their school, located at: Any of the following specified places, when Petitioner and/or proteced person(s) is/are present: c. Respondent is allowed access to the residence on (date) at (time) in the presence of (name) to remove items of clothing, personal adornments, medications used exclusively by the Respondent and other items, as follows: d. Respondent is prohibited from both physical presence and nonphysical contact with the petitioner whether direct, indirect (including, but not limited to, telephone calls, mail, email, faxes, and writings), or through third parties. **4.The Respondent is ordered to undergo counseling at for a duration of 5. a. Petitioner is granted physical care and possession of the minor child/ren; and/or b. Respondent is ordered to: Return the minor child/ren to the physical care of ; and/or from Not remove the minor child/ren the physical care of Petitioner or c. Within 24 hours of the issuance of this Order, the Circuit Clerk is requested to send written notice of the Order to any protected child's day care or school; specifically, that notice be sent to the following: **6. Petitioner is granted temporary legal custody of the minor child/ren 7. a. Respondent is awarded visitation rights on the following dates and times under the following conditions or parameters: (No order shall merely refer to the term "reasonable visitation") b. Respondent's visitation is restricted as follows: c. Respondent's visitation is denied. (Petitioner may deny Respondent access to the minor child/ren if: Respondent is under the influence of drugs or alcohol and constitutes a threat to the safety and well-being of Petitioner or Petitioner's minor child/ren, or Respondent is behaving in a violent or abusive manner.) 8. Respondent is prohibited from removing the minor child/ren from Illinois or concealing them within Illinois. 9. Respondent is ordered to appear on at m. in room at the DeKalb County Courthouse, 133 W. State St., Sycamore, IL 60178 with/without the minor child/ren. 10. Petitioner is granted exclusive possession of the following personal property and the Respondent is ordered to promptly make available to Petitioner said property that is in Respondent's possession or control, to wit: P1-OP-02 (03/06) Page 3 of 5 White - Clerk Green - Petitioner Yellow - Sheriff Pink - Respondent Gold - Attorney/SAO American LegalNet, Inc. www.USCourtForms.com Order of Protection Continued Case No. 11. The Respondent is prohibited from taking, encumbering, transferring, concealing, damaging, or otherwise disposing of the following personal property: except as explicitly authorized by the Court. Further the Respondent is prohibited from improperly using the financial or other resources of an aged member of the family or household for the profit or advantage of Respondent or any other person. **12.The Respondent is ordered to pay temporary support for the Petitioner and the minor child(ren) in the amount of $ , frequency commencing Payments are to be made directly to the Petitioner. Payments are to be made to the: Circuit Court Clerk **13.Respondent is ordered to pay $ State Disbursement Unit (Specific Form Required) as actual monetary compensation for loss(es) to on or before Further, Respondent is ordered to pay court costs in the amount of $ amount of $ to and attorney fees in the in connection with any action to obtain, modify, enforce, appeal or reopen any order of protection on or before 14. Respondent is 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 is ordered to immediately turn over any firearms in his/her possession to law enforcement agency . 15. Respondent is denied access to school and/or any other records of the minor child(ren) and is prohibited from inspecting, obtaining, or attempting to inspect or obtain such records. **16. Respondent is ordered to pay $ to the following shelter . on or before 17. Respondent is further ordered and/or enjoined as follows: 18. The relief requested in paragraph(s) because: of the petition is DENIED RESERVED **Relief available in Interim & Plenary Orders only available after actual notice Any knowing violation of any Order of Protection forbidding physical abuse, neglect, exploitation, harassment, intimidation, interference with personal liberty, willful deprivation, or entering or remaining present at specified places when the protected person is present or granting exclusive possession of the residence or household, or granting a Stay Away Order, is a Class A Misdemeanor. Grant of exclusive possession of the residence or household shall constitute notice forbidding trespass to land. Any knowing violation of any order awarding legal custody or physical care of a child, or prohibiting removal or concealment of a child may be a Class 4 Felony. Any willful violation of any order is contempt of court. Any violation may result in fine or imprisonment. Stalking is a felony. (Definitions of prohibited conduct on page 2.) P1-OP-02 (03/06) Page 4 of 5 White - Clerk Green - Petitioner Yellow - Sheriff Pink - Respondent Gold - Attorney/SAO American LegalNet, Inc. www.USCourtForms.com Order of Protection Continued Case No. PLENARY ORDERS ONLY This order shall remain in effect until: (Enter a specific date and check one below) 1. Two years following the date of entry of this Order, or such earlier date as ordered above. . 2. Final judgment in conjoined proceeding is rendered herein/case number 3. This Order is modified or vacated provided such Order is incorporated into the final judgment of case number or another civil proceeding. 4. Termination of any voluntary or involuntary commitment, or for a fixed period of time not exceeding 2 years. 5. Final disposition when a Bond Forfeiture Warrant has been issued. Case is set for warrant review on . 6. In conjunction with original case. (Fill in below) Days Months Years a. Term of Supervision/Conditional Discharge/Probation...................... b. Term of Periodic Imprisonment/Imprisonment................................... Parole/Mandatory Supervised Release (required if applicable).............. c. Term not to exceed 2 years in addition to a or b (discretionary)......... Total Expiration date set as (Fill in above) All Orders: Dismissal or withdrawl of any delinquency petition or criminal prosecution or a finding of not guilty shall not require dismissal of the action for the order of protection; shall not affect the validity of any previously issued order of protection. Emergency Order: "This Order of Protection is enforceable, even without registration, in all 50 states, the District of Columbia, tribal lands, and the U.S. territories pursuant to the Violence Against Women Act (18 U.S.C. 2265). Violating this Order of Protection may subject the respondent to federal charges and punishment (18 U.S.C. 2261-2262)." Interim or Plenary Orders: "These Orders of Protection are enforceable, even without registration, in all 50 states, the District of Columbia, tribal lands, and the U.S. territories pursuant to the Violence Against Women Act (18 U.S.C. 2265). Violating this Order of Protection may subject the respondent to federal charges and punishment (18 U.S.C. 2261-2262). The Respondent may be subject to federal criminal penalties for possessing, transporting, shipping, or receiving any firearm or ammunition under the Gun Control Act (18 U.S.C. 922(g)(8) and (9))." Date: ENTER: Judge Atty./Pro Se: Atty. Reg/Firm No.: A true copy of the original is on file in my office. Address: Attested to this City/State/Zip: Maureen A. Josh Clerk of the Circuit Court DeKalb County, Illinois Phone: By: Service in open court Deputy Clerk . Respondent P1-OP-02 (03/06) Page 5 of 5 White - Clerk Green - Petitioner Yellow - Sheriff Pink - Respondent Gold - Attorney/SAO American LegalNet, Inc. www.USCourtForms.com