CIRCUIT COURT OF ILLINOIS  Independent __________________ JUDICIAL CIRCUIT  Criminal ________________________ COUNTY  Juvenile  Other Civil Proceeding ________________________ Petitioner’s Name Case # ______________________ I am filing on behalf of:  myself minor child(ren) dependent  high risk adult _____________________________________ (Full Name) (Age) (file stamp) v. _________________________ Respondent’s Name (Person you desire protection from) VERIFIED PETITION FOR ORDER OF PROTECTION I request an Order of Protection against __________________________________________________. (Name of Respondent)  I am requesting an Emergency Order of Protection  I did not give the Respondent notice that I am seeking protection because I fear that giving notice would result in further abuse or because the abuse is likely to recur before I return to court. Good cause exists for granting the remedy or remedies requested without prior service of process or notice. PETITIONER INFORMATION Petitioner’s address for the purpose of service of notice is: (Street/P.O. Box) (City) (State) (Zip Code)  Check this box, if the above address is an Alternate Address for Service of Notice because disclosure of abused person’s actual address would risk further abuse. Petition 2 American LegalNet, Inc. www.FormsWorkflow.com Persons to be included in the Order of Protection, in addition to the Petitioner, are: Full Name Age State of Residence Relationship to Petitioner _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ ______ RESPONDENT INFORMATION Date of Birth: __________________(mmddyyyy)  Unknown Social Security Number: __________________ Sex:  Male  Female Race: _________________ Weight: _______ Height: ______ ft. ______ in. Hair color: _____________ Eye color: _________ Respondent’s Current Address: (Street/ P.O. Box) (City) (State) (Zip Code) (City) (State) (Zip Code) Respondent’s Work Address: (Street/ P.O. Box) Distinguishing Features (scars, marks, tattoos, etc.) : ______________________________________ Relationship Code The Petitoner/Abused Person stands in the following relationship to the Respondent (check all that apply): X RELATIONSHIP X RELATIONSHIP X RELATIONSHIP Spouse (SE) Parent (PA) Grandparent (GP) Ex-Former Spouse (XS) Sibling (Brother/Sister) In-Law (IL) (SB) Boyfriend/Girlfriend(BG) Step-child (SC) Person with Disability Petition 3 American LegalNet, Inc. www.FormsWorkflow.com (Dating Relationship) Shared/common (PD) Person Responsible for High- Step-sibling (SS) dwelling Risk Adult (PR) (CS) Child in Common (CC) Personal Assistant or Step-parent (SP) Caregiver to Person with (parties not married) Disability (PC) Child (CH) Other Related by Blood or Grandchild (GC) Marriage (OF) BACKGROUND INFORMATION 1. Is there or has there ever been an Order of Protection in any state and county naming you as the Petitioner or Respondent?  Yes  No If yes, please provide the following information for each Order of Protection: Date of Expiration Name of Petitioner Name of Respondent St/County Case Number (mmddyyyy) __________________ ______________________ ____________________ ________________ __________________ ______________________ ____________________ ________________ 2. Has a child/dependent/high risk adult of either party been designated as either a Respondent or protected person in any other Order of Protection, Custody, or Guardianship proceeding?  Yes  No If yes, please provide the following information for each Order: Name of Petitioner Name of Respondent Date of Expiration St/County Case Number (mmddyyyy) __________________ ______________________ ____________________ ________________ __________________ ______________________ ____________________ ________________ 3. Are there now, or have there ever been, any civil, criminal, or divorce proceedings involving you, one of the protected persons and/or the Respondent?  Yes  No  None known If yes, please list all pending cases below. Petition 4 American LegalNet, Inc. www.FormsWorkflow.com a. Type of Case: __________________________________ Result: _____________________ State/County: ______________________ Case # (if known) _____________ Date ________ b. Type of Case: __________________________________ Result: _____________________ b. Type of Case: __________________________________ Result: _____________________ State/County: ______________________ Case # (if known) _____________ Date ________ c. Type of Case: __________________________________ Result: _____________________ State/County: ______________________ Case # (if known) _____________ Date ________ 4. Venue in appropriate in this county because:  Petitioner resides in the County of __________________, State of Illinois; OR  Respondent resides in the County of ____________________, State of Illinois; OR  Illinois;  The alleged abuse occurred in the County of ________________, State of OR The petitioner is temporarily located in the County of _____________________, not obtain safe, accessible, and State of Illinois, to avoid further abuse, and could adequate temporary housing in the county of his/her residence. 5. I am requesting an Order of Protection because the Respondent did the following things on the dates and times indicated below. (Be Specific) (Include the relevant history of abuse, the effect the abuse had on you, and the date and place that each incident occurred. Attach additional pages, if necessary.) Incidents:_________________________________________________________________________ Petition 5 American LegalNet, Inc. www.FormsWorkflow.com ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ __________ Effects(s): __________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ______  Continued on attached page(s) BEGIN HERE!!!!!! B.  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: iv.  Petitioner has a right to occupancy and Respondent has no right to occupancy. OR v.  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: vi.  Availability, accessibility, cost, safety, adequacy, location, and other Petition 6 American LegalNet, Inc. www.FormsWorkflow.com characteristics of alternative housing for each party and any minors or other dependants; and/or vii.  Effect on each party=s employment; and/or viii.  Effect on the relationship of each party and any minors or ix.  Dependent adults in the care of each party, to family, school, church and community. C.  The following individuals are persons who need to be protected from abuse by Respondent ________________________________________________________ ___________________________________________________________________. D.  Respondent should be ordered to stay away from Petitioner and the Protected Persons. x.  Respondent should be prohibited from entering or remaining present at the Petitioner=s school, place of employment, or ____________________ because: xi.  Respondent has no right to enter/remain present at such place(s); OR xii.  The balance of hardships favors the Petitioner in prohibiting the Respondent from entering or remaining present at such place(s). E.  The likelihood of future abuse would be minimized by appropriate counseling. F.  As referred to herein, Athe minor child(ren)@ are the child(ren) that the parties have or allegedly have in common namely: _______________________________________ __________________________________________________________________  The court has jurisdiction over the minor child(ren) because: xiii.  1. This state: xiv. 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 xv. 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 removal or retention by a person claiming his custody or for other reasons, and a parent or person acting as a parent continues to live in this state; OR xvi.  2. It is in the best interest of the child that a court of this state assume Petition 7 American LegalNet, Inc. www.FormsWorkflow.com jurisdiction because the child and his parents, or the child and at least on contestant, have a significant connection with this state, and there is available in the State substantial evidence concerning the child=s present or future care, protection, training and personal relationships; OR xvii. 3.  The child is physically present in this state and a.  the child has been abandoned, or b.  xviii. it is necessary in an emergency to protect the child because he has been subjected to or threatened with mistreatment or abuse or is otherwise neglected or dependent; OR 4.  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. G.  No "father and child relationship" (pursuant to the Illinois Parentage Act of (1984) has been established with the following child(ren): ________________________________ ___________________________________________________________________. H.  The primary caretaker of the minor child(ren) has been _______________________ ___________________________________________________________________. I.  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: xix.  Abused or neglected; and/or xx.  Separated in an unwarranted manner from the child(ren)=s primary caretaker; and/or xxi.  Unprotected as to his/her/their well-being. J.  Petitioner should be granted temporary legal custody of the minor child(ren). K.  The Respondent's visitation with the minor child(ren) should be restricted or denied because the Respondent has or is likely to: xxii.  abuse or endanger the minor child(ren) during visitation; and/or Petition 8 American LegalNet, Inc. www.FormsWorkflow.com xxiii.  use visitation as an opportunity to abuse or harass Petitioner or Petitioner=s family or household members; and/or xxiv.  improperly conceal or detain the minor child(ren); and/or xxv.  otherwise act in a manner that is not in the best interest of the minor child(ren). L.  It is necessary to prohibit Respondent from coming to Petitioner=s residence to meet the minor child(ren) for visitation to protect any member of Petitioner=s family or household from future abuse. M.  There exists a danger that the minor child(ren) will be removed from this jurisdiction or concealed within the State. N.  Respondent has knowledge of the whereabouts of or access to the minor child(ren). O.  Petitioner should be granted exclusive possession of the following items of personal property: ___________________________________________________________ __________________________________________________________________ because: xxvi.  Petitioner, but not Respondent, owns such property; OR xxvii. Sharing the property creates a further risk of abuse or is impractical; the balance of hardships favors temporary possession by Petitioner; and xxviii.  Petitioner and Respondent own the property jointly, or xxix.  The property is alleged to be marital property and a proceeding has been filed under the IMDMA. P.  An order should be granted protecting the following items of personal property: ____________________________________________________________________ ____________________________________________________________________ because: xxx.  Petitioner, but not Respondent, owns such property; OR xxxi. The balance of hardships favors Petitioner; and xxxii.  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. Q.  Respondent has a legal obligation to support  Petitioner and/or  the minor child(ren), and Respondent is able to provide such support. Petition 9 American LegalNet, Inc. www.FormsWorkflow.com R.  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: ___________________________________________________ ___________________________________________________________________. S.  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. T.  Respondent should be denied access to school or other records of the minor child(ren) because:  xxxiii. Respondent is or will be prohibited from having contact with the minor child(ren); or  xxxiv. Petitioner=s address is omitted pursuant to statute; or  xxxv. It is necessary to prevent abuse or wrongful removal or concealment of the minor child(ren). U.  Allegations for other injunctive relief: _____________________________________ ________________________________________________________________________ ________________________________________________________________________ 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 Petition 10 American LegalNet, Inc. www.FormsWorkflow.com given of Petitioner=s effort to obtain judicial relief, or that Petitioner has an immediate and pressing need for possession of that property. REQUESTED REMEDIES 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 be prohibited from committing the following:   Harassment;  Intimidation of a dependant;  Neglect;  Interference with  Willful Deprivation;  Exploitation; personal liberty. Petitioner be granted exclusive possession of the residence and Respondent be  Physical Abuse; 2.  Stalking; prohibited from entering or remaining at such premises ______________________ ___________________________________________________________________. 3.  Respondent be ordered to stay away from Petitioner and other Protected Persons; and/or  xxxvi. Respondent be prohibited from entering or remaining at __________________ ______________________________________________________________ while any Protected Person is present; and/or  xxxvii. Respondent be allowed access to the residence to remove items of clothing, personal adornments, medications used exclusively by the Respondent and other items, as follows: ___________________________________________ _____________________________________________________________. 4.  Respondent be ordered to undergo counseling for a period of time to be determined by this court. (Not available in Emergency Order) 5.  a. Petitioner be granted physical care and possession of the minor child(ren;) and/or Petition 11 American LegalNet, Inc. www.FormsWorkflow.com  b. Respondent be ordered to:  xxxviii. Return the minor child(ren) ____________________________ __________________________________________________ to the physical care of ________________________________ ____________________________________________; and/or  xxxix. Not remove the minor child(ren) ________________________ __________________________________________________ from the physical care of Petitioner or ___________________ __________________________________________________. 6. Petitioner be granted temporary legal custody of the minor child(ren): ____________ __________________________________________________________________. (Not available in Emergency Order)  7. a.  Respondent be awarded visitation rights on the following dates and times or under the following conditions or parameters: ____________ _______________________________________________________ _______________________________________________________. b.  Respondent=s visitation be restricted as follows: _________________ _______________________________________________________ _______________________________________________________. c.  Respondent's visitation be denied. d.  Respondent be prohibited from meeting the minor child(ren) for visitation at Petitioner=s residence and may meet child(ren) at:_______ _______________________________________________________ _______________________________________________________.  8. Respondent be prohibited from removing the minor child(ren) from Illinois or concealing him/her/them within Illinois.  9. 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 make available to Petitioner the following Petition 12 American LegalNet, Inc. www.FormsWorkflow.com property which is in the Respondent=s possession or control: ________________________ ___________________________________________________________________ ___________________________________________________________________.  11. Respondent be ordered not to take, transfer, encumber, conceal, damage, or otherwise dispose of any of the following real or personal property: _____________________________________________________________________ __________________________________________________________________.  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. (Not available in Emergency Order)  13. Respondent 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 be prohibited from entering or remaining in the residence located at ____________________________________________________________________ ____________________________________________________________________ while under the influence of drugs or alcohol and so constituting a threat to the safety and well-being of any Protected Person.  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: ___________________________________________________________________ ____________________________________________________________________ ___________________________________________________________________. Petition 13 American LegalNet, Inc. www.FormsWorkflow.com ________________________________ Signature of Attorney or State=s Attorney __________________________ Signature of Petitioner Petition 14 American LegalNet, Inc. www.FormsWorkflow.com UNDER THE PENALTIES AS PROVIDED BY LAW PURSUANT TO SECTION 1-109 OF THE CODE OF CIVIL PROCEDURE, THE UNDERSIGNED, BEING FIRST DULY SWORN ON OATH, STATES THAT SHE/HE HAS READ THE FOREGOING PETITION FOR ORDER OF PROTECTION BY HER/HIS SUBSCRIBED AND THAT THE FACTS STATED THEREIN ARE TRUE TO THE BEST OF HER/HIS KNOWLEDGE AND BELIEF. ________________________________ Signature of Petitioner Subscribed and Sworn to before me this _________ day of _____________, 20 ___. ___________________________________ Notary Public Attorney (or Pro Se Petitioner) Name: ________________________________________________ Address: ______________________________________________________________________ City: ________________________________________________________________________ Phone: ________________________________________________________________________ Service by Facsimile  will be accepted  will not be accepted Facsimile Number must be included if service by facsimile is accepted. _______________________ Petition 15 American LegalNet, Inc. www.FormsWorkflow.com