CIRCUIT COURT OF ILLINOIS NINETEENTH JUDICIAL CIRCUIT LAKE COUNTY Independent Criminal Juvenile Petitioner’s Name (person completing form) Check if filing on behalf of: a minor child, or an adult who because of age, disability, health, or inaccessibility cannot file the Petition (list the name(s) below) (file stamp) Name(s) of additional Petitioner(s) vs. Case Number Respondent’s Name (person you want protection from) (to be completed by Court) MOTION TO EXTEND AND/OR MODIFY CIVIL NO CONTACT ORDER I request that the Civil No Contact Order be extended or modified because: (Be specific) and request that the matter be set for hearing. WHEREFORE, Petitioner moves the Court to grant the relief requested in this Motion. VERIFICATION UNDER THE PENALTIES OF PERJURY 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 HEREIN STATED TO BE ON INFORMATION AND BELIEF AND AS TO SUCH MATTERS THE UNDERSIGNED CERTIFIES AS AFORESAID THAT THE UNDERSIGNED VERILY BELIEVES THE SAME TO BE TRUE. Signature of Petitioner Petitioner’s Attorney or Petitioner if not represented by an attorney Name: Telephone Number: Address: City/State/Zip: Form approved by the Conference of Chief Circuit Judges Effective: January 1, 2005 Page 1 of 1 – Motion to Extend/Modify Civil No Contact Order American LegalNet, Inc. www.USCourtForms.com 171- (12/04)