IN THE CIRCUIT COURT OF THE SIXTEENTH JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS Case No. Plaintiff/Petitioner Defendant/Respondent File Stamp VERIFIED PETITION FOR ORDER OF PROTECTION (Fill in lines and check boxes as applicable) Independent Proceeding Criminal Proceeding Matrimonial Other: on his/her own Now comes the Petitioner behalf or on behalf of , a minor child(ren), 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 Petitioner resides at ; OR (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 C. State of Respondent stands in relationship to the Petitioner or alleged abused person/s as: Spouse; Former Spouse; Parent; Child(ren); Stepchild(ren); Sharing or formerly sharing a common dwelling; Having or allegedly having a child in common; Having or having had dating or engagement relationship; Sharing a blood relationship through child(ren); Personal assistant to person with disabilities or a person who has responsibility for a high-risk adult with disabilities; P1-OP-01 (03/06) Page 1 of 5 White - Clerk Green - Petitioner Yellow - Sheriff Pink - Respondent Other person related by blood or marriage; Gold - Attorney/SAO American LegalNet, Inc. www.USCourtForms.com Verified Petition for Order of Protection Continued D. There is no other pending court action involving the parties, OR There is another pending court action involving the parties in County of E. Case No. State of Court, known as Case No. 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) F. Venue in civil proceedings is appropriate because: Petitioner resides in the County of DeKalb, State of Illinois; OR Respondent resides in the County of DeKalb, State of Illinois; OR The alleged abused occurred in the County of DeKalb, State of Illinois; OR The Petitioner is temporarily located in the County of DeKalb, 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: G. The following individual(s) are alleged to be person(s) who need to be protected from abuse by Respondent: (full name, D.O.B) H. Respondent has acted in the following manner toward the Abused: [State details of incident(s) of abuse (including time and place)] P1-OP-01 (03/06) Page 2 of 5 White - Clerk Green - Petitioner Yellow - Sheriff Pink - Respondent Gold - Attorney/SAO American LegalNet, Inc. www.USCourtForms.com Case No. Verified Petition for Order of Protection Continued ADDITIONAL ALLEGATIONS FOR EMERGENCY ORDERS ONLY I. J. K. 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. 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. 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. WHEREFORE, PETITIONER REQUESTS THE ENTRY OF AN ORDER OF PROTECTION SETTING FORTH THE FOLLOWING REMEDIES: 1. With respect to Petitoner and other Protected Person(s), Respondent be prohibited from commiting the following: Physical abuse; Harassment; Interference with personal liberty; Intimidation of a dependent; Willful deprivation; Neglect; Exploitation; Stalking. P1-OP-01 (03/06) Page 3 of 5 White - Clerk Green - Petitioner Yellow - Sheriff Pink - Respondent Gold - Attorney/SAO American LegalNet, Inc. www.USCourtForms.com Case No. Verified Petition for Order of Protection Continued 2. 3. Petitioner be granted exclusive possession of the residence and Respondent be prohibited from entering or remaining at such premises: (address + county) a. Respondent be ordered to stay away from Petitioner and other protected persons; and/or b. Respondent be prohibited from entering or remaning at while any Protected Person is present; and/or c. Respondent be allowed access to the residence on (date) at (time) in the presence of (name) to remove items of clothing, personal adornments, medication used exclusively by the Respondent and other items, as follows: 4. 5. d. Respondent be 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. Respondent be ordered to undergo counseling for a period of time to be determined by this court. (Not available in Emergency Order) a. Petitioner be granted physical care and possession of the minor child/ren; and/or b. Respondent be ordered to: 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. 7. Petitioner be granted temporary legal custody of the minor child/ren (Not available in Emergency Order) a. Respondent 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 be restricted as follows: c. Respondent's visitation be denied 8. 9. Respondent be prohibited from removing the minor child(ren) from Illinois or concealing them within Illinois. Respondent be ordered to appear in this Court with/without the child(ren) on a date certain. 10. Petitioner be granted exclusive temporary possession of the following personal property and the Respondent be ordered to deliver to Petitioner said property that is in Respondent's possession or control, to wit: P1-OP-01 (03/06) Page 4 of 5 White - Clerk Green - Petitioner Yellow - Sheriff Pink - Respondent Gold - Attorney/SAO American LegalNet, Inc. www.USCourtForms.com Case No. Verified Petition for Order of Protection Continued 11. Respondent be ordered not to take, encumber, conceal, damage or otherwise dispose of any of the following real or personal property, to wit: 12. Respondent 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 13. Respondent be ordered to pay $ directly to Petitioner. (Not available in Emergency Order) respecting losses and expenses within the scope of Sec. 214(b)(13) of the IDVA to (Not available in Emergency Order) on or before 14. Respondent be prohibited from entering or remaining at 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 the Protected Person. 14-5. Respondent be ordered to turn over any firearms in his/her possession to law enforcement. (Not available in Emergency Order) 15. Respondent 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 be ordered to pay $ to the following shelter on or before (Not available in Emergency Order) 17. Respondent be further enjoined as follows: Signature of Attorney or State's Attorney Signature of Petitioner 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 THEREIN STATED TO BE INFORMATION AND BELIEF AND AS SUCH MATTERS THE UNDERSIGNED CERTIFIES AS AFORESAID THAT THE UNDERSIGNED VERILY BELIEVES THE SAME TO BE TRUE. Signature of Petitioner Atty./Pro Se: Atty. Reg/Firm No.: Address: City/State/Zip: Phone: P1-OP-01 (03/06) Page 5 of 5 White - Clerk Green - Petitioner Yellow - Sheriff Pink - Respondent Gold - Attorney/SAO American LegalNet, Inc. www.USCourtForms.com