ORDER OF PROTECTION INFORMATION WORKSHEET (This worksheet list most of the information you should bring with you to help complete your Petition) INFORMATION ON PERSON MAKING THE REQUEST (PETITIONER) Petitioner's Full Name: Case No: Date of Birth: (mmddyyyy) Your Age as of today: Petitioner/Abused Person stands in relationship to the Respondent as: (check all that apply) RELATIONSHIP Spouse (SE) Ex-Former Spouse (XS) Boyfriend/Girlfriend (BG) (Dating Relationship) Child in Common (CC) (parties not married) Shared/common dwelling (CS) RELATIONSHIP Parent (PA) Sibling (Brother/Sister) (SB) Step-child (SC) RELATIONSHIP Grandparent (GP) In-Law (IL) Person with Disability (PD) Step-sibling (SS) Person Responsible for High-Risk Adult (PR) Step-parent (SP) Personal Assistant or Caregiver to Person with Disability (PC) Child (CH) Grandchild (GC) Other Related by Blood or Marriage (OF) MINOR CHILD(REN) OR ADULTS WHO CAN NOT FILE BECAUSE OF AGE, HEALTH, DISABILITY OR INACCESSIBILITY TO BE INCLUDED ON THE ORDER Full Name Relationship to Petitioner Age Have You ever asked for an Order of Protection before? Yes No When: Where: Was the Order: Given Extended Terminated Refused Was it an Emergency Order (21 Days) Yes No Case No: (If known) __________________ Is there or has there ever been an Order of Protection against YOU? Yes No Currently Pending Terminated on _____________ Has the child(ren) of either party been designated as a Respondent or a protected person in any Order of Protection: No Yes If Yes, where and what is/was the expiration date? ______________________ Do YOU or the RESPONDENT have any case(s) pending in any court? YOU RESPONDENT Criminal Case Criminal Case Divorce/Family Case/Custody Divorce/Family Case/Custody Small Claims Case Small Claims Case Probate Case Probate Case Juvenile Matter Juvenile Matter Other ____ Other _____ Do You have any future court dates? No Yes When? ___________________________________ Respondent? No Yes When? ___________________________________ Do You or the Respondent have an attorney? YOU: No Yes RESPONDENT: No Yes Name of Attorney ___ Name of Attorney ___ Attorney Phone No: ______________________ Attorney Phone No: ______________________ PETITIONER'S RESIDENCE INFORMATION Actual Address (Street/P.O. Box, City, State, Zip Code): Alternate Address for Service of Notice because disclosure would risk further abuse: American LegalNet, Inc. www.USCourtForms.com SECONDARY ADDRESS(ES) TO PROTECT (i.e. Schools, Day Care, Relatives, etc.) Phone # Address: Phone # Address: Phone # Address: PETITIONER'S EMPLOYMENT INFORMATION Business Name: Petitioner's Work Address (Street/P.O. Box, City, State, Zip Code): Business Phone: Normal Work Hours: PETITIONER'S VEHICLE INFORMATION Vehicle Make: Vehicle Model: Vehicle Year: License Plate #: Vehicle Color: I am requesting an Order of Protection because the Respondent did the following things on the dates and times indicated below: (You may include relevant history of abuse and its effect(s) on you and the date and place each incident occurred; Attach additional pages, if necessary) Date(s) & Location By City/State Description of Incident(s) Continued on attached page(s) American LegalNet, Inc. www.USCourtForms.com INFORMATION ON PERSON TO BE SERVED (RESPONDENT) Respondent's Full Name: DATE OF BIRTH AGE HEIGHT WEIGHT HAIR COLOR EYE COLOR SEX RACE GLASSES BUILD Distinguishing Features (scars, marks, tattoos, etc.): Social Security Number (if known): Respondent's Current Address (Street, City, State, Zip Code, Phone): RESPONDENT'S EMPLOYMENT INFORMATION Business Name: Respondent's Work Address (Street/P.O. Box, City, State, Zip Code): Business Phone: Normal Work Hours: RESPONDENT'S VEHICLE INFORMATION Vehicle Make: License Plate #: Vehicle Model: Vehicle Color: Vehicle Year: RESPONDENT'S FIREARMS AND CUSTODY INFORMATION Is the person to be served a violent person? Yes No Was the subject to be served arrested? Yes No Is the subject now in custody? Yes No Is the person to be served suicidal? Yes Which Department? Does the person to be served carry any weapons on said person? Are there any weapons in the house? Yes No Yes No No If yes, give location in the house: Types of Weapons? Comments: (Include other relevant information not mentioned above or additional information covered above) Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth are true and correct, except as to matters therein stated to be on information an belief and as to such matters the undersigned certifies as aforesaid that he/she verily believes the same to be true. Date: Signature of Petitioner: American LegalNet, Inc. www.USCourtForms.com DEFINITION OF TERMS USED IN ORDERS OF PROTECTION These definitions are incorporated in and made a part of the order to which they are attached. 1. Abuse: “Abuse” means physical abuse, harassment, 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. 2. Domestic Violence: Domestic Violence means abuse as defined in paragraph one. 3. Exploitation: “Exploitation” means the illegal, including tortuous, 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 misappropriation of assets or resources of a high-risk adult with disabilities by undue influence, by breach of a fiduciary relationship, by fraud, deception, or extortion, or the use of such assets or resources in a manner contrary to law. 4. Family or Household Members: Include spouses, former spouses, parents, children, stepchildren and other persons related by blood or by present or prior marriage, persons who share or formerly shared a common dwelling, persons who have or allegedly have a child in common, persons who share or allegedly share a blood relationship through a child, persons who have or have had a dating or engagement relationship, and persons with disabilities and their personal assistants. For purposes of this paragraph, neither a casual acquaintanceship nor ordinary fraternization between two individuals in business or social contexts shall be deemed to constitute a dating relationship. In the case of a high-risk adult with disabilities, “family or household members” includes any person who has the responsibility for a high-risk adult as a result of a family relationship or who has assumed responsibility for all or a portion of the care of a high-risk adult with disabilities voluntarily, or by express or implied contract, or by court order. 5. Harassment: “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) repeatedly threatening to improperly remove a child of petitioner’s from the jurisdiction, improperly concealing that child from petitioner or making a single such threat following an actual or attempted improper removal or concealment; f) improperly concealing a minor child from petitioner, repeatedly threatening to improperly remove a minor child of petitioner 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; or g) threatening physical force, confinement or restraint on one or more occasions. American LegalNet, Inc. www.USCourtForms.com 6. Interference with Personal Liberty: “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. 7. Intimidation of a Dependent: “Intimidation” 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 herein defined, regardless of whether the abused person is a family or household member. 8. Neglect: “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 disabilities who requires 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. 9. Physical Abuse: “Physical abuse” includes sexual abuse and means any of the following: a) knowing or reckless use of physical force, confinement, or restraint; or b) knowing, repeated and unnecessary sleep deprivation; or c) knowing or reckless conduct which creates an immediate risk of physical harm. 10.Stalking: “Stalking” means knowingly and without lawful justification, on at least two (2) separate occasions, following another person or placing the person under surveillance or any combination thereof and: a) at any time transmitting a threat of immediate or future bodily harm, sexual assault, confinement or restraint and the threat is directed towards that person or a family member of that person; or b) placing that person in reasonable apprehension of immediate or future bodily harm, sexual assault, confinement or restraint; or c) placing that person in reasonable apprehension that a family member will receive immediate or future bodily harm, sexual assault, confinement, or restraint. 11.Willful Deprivation: “Willful deprivation” means willfully denying a person who because of age, health or disability requires medication, medical care, shelter, 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 forego such medical care or treatment. This paragraph does not create any new affirmative duty to provide support to dependent persons. American LegalNet, Inc. www.USCourtForms.com