CIRCUIT COURT OF ILLINOIS NINETEENTH JUDICIAL CIRCUIT LAKE COUNTY Independent Criminal Juvenile Petitioner’s Name (person completing form) Check if filing on behalf of: minor child, or an adult who because of a age, disability, health, or inaccessibility cannot file the Petition (list 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) VERIFIED PETITION FOR CIVIL NO CONTACT ORDER (Sexual Conduct and/or Penetration) PETITIONER INFORMATION Name: Address: (Street/P.O. Box) (City) (State) (Zip Code) Disclosure of Petitioner’s address would risk further abuse. The address listed above is Petitioner’s alternative address for service of notice. RESPONDENT INFORMATION (if known) Name: Sex: DOB: Male Female Race: Eye Color: Hair Color: Height: Weight: Social Security #: License Plate #: Driver’s License #: Description: Other Numeric Identifier: (number) (e.g. passport #, military serial # or other) Home Address: (Street/P.O. Box) (City) Name of Workplace: (State) (Zip Code) Work Hours: Work Address: (Street/P.O. Box) (City) (State) (Zip Code) Distinguishing Physical Features: (tattoos, scars, etc.) Form approved by the Conference of Chief Circuit Judges Effective: January 1, 2005 Page 1 of 4 – Petition for Civil No Contact Order American LegalNet, Inc. www.USCourtForms.com 171- (12/04) Respondent may be: considered armed and/or dangerous suicidal considered armed, dangerous and suicidal , at I am requesting a Civil No Contact Order because on or about (date) , (location) the following occurred: (Be specific) (Additional pages may be added) Venue is appropriate in this county because: the Petitioner resides here; the Respondent resides the alleged non-consensual sexual conduct or non-consensual sexual penetration occurred here here; (check all that apply). American LegalNet, Inc. www.USCourtForms.com Page 2 of 4 – Petition for Civil No Contact Order 171- (12/04) REMEDIES SECTION (740 ILCS 22/213) Pursuant to the Civil No Contact Order Act, the Petitioner seeks the following remedies: 1. Stay Away and Additional Prohibitions. That the Respondent be ordered to stay at least ________ feet away from the Petitioner, and not communicate with Petitioner in any way, directly, indirectly or through third parties, including, but not limited to, phone, written notes, mail, e-mail, or fax. That the Respondent be prohibited from entering or remaining while Petitioner is present at her/his: place of residence, currently located at place(s) of employment, located at school(s), located at and any of the following specified places, when Petitioner is present: 2. Other Injunctive Relief as Follows: . WHEREFORE, Petitioner moves the Court to grant the relief requested in this Petition. 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: American LegalNet, Inc. www.USCourtForms.com Page 3 of 4 – Petition for Civil No Contact Order 171- (12/04) DEFINITION OF TERMS USED IN THIS PETITION 1. Civil No Contact Order: an emergency order or plenary order granted under this Act, which includes a remedy authorized by 740 ILCS 22/213 of this Act. 2. Non-Consensual: a lack of freely given agreement. 3. Petitioner: any named Petitioner for the no contact order or any named victim of non-consensual sexual conduct or non-consensual sexual penetration on whose behalf the petition is brought. 4. Sexual Conduct: any intentional or knowing touching or fondling by the Petitioner or the Respondent, either directly or through clothing, of the sex organs, anus, or breast of the Petitioner or the Respondent, or any part of the body of a child under 13 years of age, or any transfer or transmission of semen by the Respondent upon any part of the clothed or unclothed body of the Petitioner, for the purpose of sexual gratification or arousal of the Petitioner or the Respondent. 5. Sexual Penetration: any contact, however slight, between the sex organ or anus of one person by an object, the sex organ, mouth or anus of another person, or any intrusion, however slight, of any part of the body of one person or any animal or object into the sex organ or anus of another person, including but not limited to cunnilingus, fellatio or anal penetration. Evidence of emission of semen is not required to prove sexual penetration. 6. Stay Away: to refrain from both physical presence and non-physical contact with the Petitioner directly, indirectly, or through third parties who may or may not know of the order. “Non-physical contact” includes, but is not limited to, telephone calls, mail, e-mail, fax and written notes. American LegalNet, Inc. www.USCourtForms.com Page 4 of 4 – Petition for Civil No Contact Order 171- (12/04)