CIRCUIT COURT OF ILLINOIS NINETEENTH JUDICIAL CIRCUIT LAKE COUNTY Case # Petitioner’s Name (Person desiring protection) I am filing on behalf of: myself minor child(ren) dependent Independent Criminal Juvenile Other Civil Proceeding high risk adult: (file stamp) (Full Name) (Age) 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 The 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. 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) Social Security Number: Weight: Height: Unknown Sex: ft. in. Male Female Hair color: Race: 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.): Form approved by the Conference of Chief Circuit Judges Effective November 1, 2004 Use required after July 1, 2005 Page 1 of 11 – Petition American LegalNet, Inc. www.USCourtForms.com 171-37 Rev. 11/04 RELATIONSHIP CODE The Petitioner/Abused Person stands in the following relationship to the Respondent (check all that apply): RELATIONSHIP RELATIONSHIP 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 (PD) (Dating Relationship) Child in Common (CC) Step-sibling (SS) Person Responsible for High-Risk Adult (PR) (parties not married) Shared/common dwelling Step-parent (SP) Personal Assistant or (CS) Caregiver to Person with Disability (PC) Child (CH) Grandchild (GC) Other Related by Blood or 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: Name of Petitioner Name of Respondent St/County Case Number Date of expiration (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 St/County Case Number Date of expiration (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. Result: a. Type of Case: State/County: Case # (if known) Result: b. Type of Case: State/County: Case # (if known) Date Result: c. Type of Case: State/County: Date Case # (if known) Date 4. Venue is appropriate in this county because: The Petitioner resides here. The Respondent resides here. The abuse occurred here. The Petitioner is here temporarily to avoid abuse. Page 2 of 11 – Petition American LegalNet, Inc. www.USCourtForms.com 171-37 Rev. 11/04 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) Date(s) Description of Incident(s) Continued on attached page(s) Page 3 of 11 – Petition American LegalNet, Inc. www.USCourtForms.com 171-37 Rev. 11/04 REMEDIES SECTION (750 ILCS 60/214) PURSUANT TO THE ILLINOIS DOMESTIC VIOLENCE ACT (“THE ACT”), THE PETITIONER SEEKS THE FOLLOWING REMEDIES: PART A. REMEDIES INVOLVING PERSONAL PROTECTION 1. (R01) With respect to all protected persons, that the Respondent be prohibited from committing the following acts of abuse or threats of abuse (check all that apply): Harassment, interference with personal liberty, physical abuse, or stalking. Intimidation of a dependent. Willful deprivation. Neglect. Exploitation. 2. (R03) That Respondent be ordered to stay away from Petitioner and other protected person(s). a. That the Respondent be ordered to stay person(s). ft. away from Petitioner and other protected b. That the Respondent is ordered to stay other protected person(s), currently located at ft. away from the residence of Petitioner and/or . c. That Respondent be ordered not to communicate in any way – directly, indirectly, or through third parties - with Petitioner and/or other protected persons, including, but not limited to phone, written notes, mail, email, or fax. d. That Respondent be prohibited from entering or remaining while Petitioner and/or protected person(s) is/are present at: Their place of residence, currently located at . Their place(s) of employment, located at . Their day care / school(s), located at . Any of the following specified places, when Petitioner and/or protected person(s) is/are present: . 3. (R14) That Respondent be prohibited from entering or remaining in the residence or household while under the influence of drugs or alcohol and constituting a threat to the safety or well-being of Petitioner or Petitioner’s children. Page 4 of 11 – Petition American LegalNet, Inc. www.USCourtForms.com 171-37 Rev. 11/04 PART B. REMEDIES INVOLVING PROPERTY (These remedies do not affect title to property (750 ILCS 60/214(b)(2)). 1. (R02) That the Petitioner be granted exclusive possession of, and Respondent be prohibited from entering or remaining present at the residence/household located at: (Street) (City) (State) (Zip Code) (Check one) Petitioner has a right to occupancy and Respondent has no such right, or Petitioner and Respondent both have right to occupancy, but the balance of hardships favors Petitioner’s occupancy over Respondent’s. 2. (R10) That with respect to personal property possession should be awarded as follows: a. Petitioner be granted the following personal property: . b. That the Respondent be ordered to promptly make available to the Petitioner the following property over which the Respondent has possession or control: . (Check as applies) The Petitioner, but not Respondent, owns the property, or The property is jointly owned by the parties, and sharing it would risk abuse or is impracticable and the balance of hardships favors temporary possession by Petitioner, and/or Petitioner claims property as marital property, and a proceeding has been filed under the Illinois Marriage and Dissolution of Marriage Act (“IMDMA”). c. That Respondent be given his/her clothing personal adornments medicine . other personal property, namely 3. (R10) That personal property be transferred: at the residence, or at (Street) (City) (State) (Zip Code) That the transfer of personal property take place in the presence of: law enforcement, or an agreed-upon third party, namely Respondent Petitioner have the right to enter the residence to retrieve the property but only in the presence of law enforcement or the designated third party. Time and date of transfer: 4. (R11) That Respondent be prohibited from taking, transferring, encumbering, concealing, damaging, or otherwise disposing of the following real and/or personal property: . (Check as applies) Petitioner, but not Respondent, owns the property, or The Parties own the property jointly, and the balance of hardships favors granting this remedy, and/or Petitioner claims property as marital property and a proceeding has been filed under the IMDMA. 5. (R11) That Respondent be prohibited from using financial or other resources of an aged member of the family or household for the profit or advantage of Respondent or any other person. Page 5 of 11 – Petition American LegalNet, Inc. www.USCourtForms.com 171-37 Rev. 11/04 PART C. REMEDIES INVOLVING CHILDREN List the full name, age, and the state of residence of all children not listed on page 1 of this petition whose custody and or visitation may be affected by the issuance of an order of protection against the respondent. Any prior Orders of Protection, Custody or Guardianship proceedings affecting the child should be listed in the Background Information (page 2 of 11) of this petition. Full Name Age State of Residence 1. That the primary caretaker of the minor child(ren) is Petitioner Relationship to Petitioner Respondent Other Person: (Name and Address) 2. (R05) That Petitioner be granted the physical care and possession of the minor child(ren) of the parties, and that: a. Respondent be ordered to return the minor children to the physical care of: Petitioner Other (Name and Address) on at am/pm in the . presence of b. Respondent be ordered not to remove the minor child(ren) from the physical care of the Petitioner, school/school grounds, or babysitter/daycare provider. c. Within 24 hours of the issuance of the Order, the Circuit Clerk is directed to send written notice of the Order to any protected child’s day care or school, specifically to the following: (Provide child’s name, then Name and Address for each child's school / day care) 3. (R06) That the Court award Petitioner temporary custody of the minor child(ren) of the parties. (Please note, temporary custody is not available as a remedy in an emergency order of protection). a. The children were born prior to or during the course of the marriage between the parties; b. The parties are unmarried; the children are children in common of the parties; and there has / has not been a legal determination of parentage. c. If neither of the above applies, please explain here: . Page 6 of 11 – Petition American LegalNet, Inc. www.USCourtForms.com 171-37 Rev. 11/04 4. (R07) (Visitation) That the Court provide for visitation as follows: a. Deny/ Restrict visitation because the Respondent has or is likely to: Abuse or endanger the minor child(ren) during visitation. Use visitation as an opportunity to abuse or harass Petitioner, Petitioner’s family, or household members. Improperly conceal or detain the minor child(ren). Act in a manner that is not in the best interest of the minor child(ren). b. Reserve visitation until further hearing. c. Allow the Respondent to have visitation with the minor child(ren): Every _________________________________ from am/pm to am/pm. Each weekend from am/pm to am/pm. Every other weekend from am/pm to am/pm. . Other: from Holidays: am/pm to am/pm. d. Due to the necessity of protecting Petitioner from further abuse, that Respondent be prohibited from going to Petitioner’s residence to meet the minor child(ren) for visitation. e. That the Respondent be ordered to pick up and return the child(ren) for visitation at: . (Street Address / City / State) f. That visitation take place at (Street Address / City / State) and that transportation be provided by . who has filed or will g. That visitation be supervised by file an affidavit accepting responsibility and acknowledging accountability to the Court. h. Further, that the court order the Respondent to return the child(ren) to Petitioner or Petitioner’s designated person immediately at the end of visitation. i. That the Respondent be allowed visitation that the Court finds to be in the best interests of the child(ren). 5. (R08) That the Respondent be ordered not to conceal the minor child(ren) within the State or remove the child(ren) from the State of Illinois. 6. (R09) That the Respondent be ordered to appear in Court Alone With the minor children To prevent abuse, neglect, removal or concealment of the child, To return the child to the custody or care of the Petitioner, or To permit a court-ordered interview or examination of the child or Respondent. 7. (R15) That Respondent be denied access to and be prohibited from inspecting, obtaining, or attempting to inspect or obtain school or any other records of the minor child(ren) in the care of the Petitioner because: Petitioner is requesting that the Order of Protection prohibit Respondent from having contact with the minor child(ren), or Petitioner’s actual address is omitted due to the risk of further abuse, or It is necessary to prevent abuse or wrongful removal or concealment of the minor child(ren). Page 7 of 11 – Petition American LegalNet, Inc. www.USCourtForms.com 171-37 Rev. 11/04 PART D. FIREARMS (Respondent must be present in court or have had actual notice of these proceedings before a turnover of firearms can be ordered.) 1. (R14.5) That the Respondent be ordered to turn over any and all firearms in his/her possession to a law enforcement agency because: Respondent has used or threatened to use firearms against me, and/or is likely to use firearms illegally against me. Further, Respondent possesses a firearm. has a history of violence. has a history of possession/use of firearms. carries a firearms on his/her person in a vehicle. ) (Make and model of vehicle: may be a threat to the safety of the public or police officer when encountered. is, or has been known to be, suicidal. 2. The Respondent has the following firearms (describe each): Description Location PART E. ECONOMIC REMEDIES (Economic remedies are not available at the Emergency hearing.) 1. (R12) That the Court order payment of support. a. Petitioner requests that Respondent be ordered to pay temporary child support. b. Petitioner requests that Respondent be ordered to pay temporary support to the Petitioner. c. Respondent is unemployed employed by: at (Employer) and has an approximate take-home pay of $ monthly. ___/___ of the month (Street Address) weekly (City/State) bi-weekly 2. (R13) That Respondent be ordered to pay Petitioner for losses suffered as a direct result of abuse, neglect, or exploitation, including: Medical expenses $ (if known) Lost earnings Repair/replacement of property damaged or taken $ (if known) $ (if known) Reasonable attorneys’ fees $ (if known) Moving and other travel expenses $ Reasonable expenses for housing other than a domestic violence shelter/meals $ Expenses for search and recovery of children $ (if known) (if known) (if known) Other $ (if known) If you desire payment for any of the above, please bring documentation (receipts, etc.) to the hearing. 3. (R16) That Respondent be ordered to reimburse a shelter providing temporary housing or counseling to Petitioner. Page 8 of 11 – Petition American LegalNet, Inc. www.USCourtForms.com 171-37 Rev. 11/04 PART F. MISCELLANEOUS REMEDIES 1. (R04) That the Respondent be ordered to undergo and successfully complete counseling. (If you desire that the Respondent undergo counseling, you should check this box, but this remedy is not available at the Emergency hearing.) 2. (R17) That Respondent be further ordered and enjoined 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 therein 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 Attorney for Petitioner: Name: Address: City: Phone: State: Zip Code: Fax: ARDC: Page 9 of 11 – Petition American LegalNet, Inc. www.USCourtForms.com 171-37 Rev. 11/04 DEFINITION OF TERMS USED IN THIS PETITION 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. Page 10 of 11 – Petition American LegalNet, Inc. www.USCourtForms.com 171-37 Rev. 11/04 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. Page 11 of 11 – Petition American LegalNet, Inc. www.USCourtForms.com 171-37 Rev. 11/04