CIRCUIT COURT OF ILLINOIS THIRD JUDICIAL CIRCUIT MADISON COUNTY Petitioner (person seeking protection) vs. Respondent (person you want protection from) No. OP (PRINT ALL REQUIRED INFORMATION CLEARLY) ORDER OF PROTECTION [ ] Emergency [ ] Interim [ ] Plenary PETITIONER INFORMATION Name: Address: Street [] DOB / /_____ Mo Day Year City IL Zip The address listed above is Petitioner's alternative address for service of Notice and is not Petitioner's residence address. RESPONDENT INFORMATION Name: Sex: [ ]M [ Hair Address: Street Work Address: Company Street/PO Box ]F Race Eyes Height DOB / /____ Mo Day Year Weight Social Security Number City IL Zip City IL Zip Behavior Code: Respondent is [ ] Armed [ ] Dangerous [ ] Suicidal (See Petition) [ ] Mark if the Respondent is a law enforcement officer. THIS ORDER WILL EXPIRE ON: Date Time THIS ORDER WAS ISSUED ON: Date Time (am/pm) (am/pm) Hearing for extension of Emergency Order/Entry of Plenary Order set on at (am/pm) in Courtroom Madison County Courthouse, Edwardsville, IL NOTICE TO RESPONDENT ANY KNOWING VIOLATION OF AN ORDER OF PROTECTION FORBIDDING PHYSICAL ABUSE, NEGLECT EXPLOITATION, HARASSMENT, INTIMIDATION, INTERFERENCE WITH PERSONAL LIBERTY, WILLFUL DEPRIVATION, OR ENTERING OR REMAINING PRESENT AT SPECIFIED PLACES WHEN THE PROTECTED PERSON IS PRESENT, OR GRANTING EXCLUSIVE POSSESSION OF THE RESIDENCE OR HOUSEHOLD OR GRANTING A STAYAWAY ORDER IS A CLASS A MISDEMEANOR. THE GRANTING OF EXCLUSIVE POSSESSION OF THE RESIDENCE OR HOUSEHOLD SHALL CONSTITUTE NOTICE FORBIDDING TRESPASS TO LAND. ANY KNOWING VIOLATION OF AN ORDER AWARDING LEGAL CUSTODY OR PHYSICAL CARE OF A CHILD OR PROHIBITING REMOVAL OR CONCEALMENT OF A CHILD MAY BE A CLASS 4 FELONY. STALKING IS A CLASS 4 FELONY FOR A FIRST OFFENSE AND CLASS 3 FOR A SUBSEQUENT OFFENSE. ANY WILFUL VIOLATION OF ANY ORDER IS CONTEMPT OF COURT AND MAY RESULT IN FINE OR IMPRISONMENT. 2002 � American LegalNet, Inc. FINDINGS THE COURT HAVING CONSIDERED ALL RELEVANT FACTORS PURSUANT TO STATUTE, FINDS THAT IT HAS JURISDICTION OVER THE SUBJECT MATTER OF THIS CASE, AND THAT: [] [] [] Irreparable injury would be likely to occur if the Respondent were given prior notice or greater notice than was given of the Petitioner's efforts to obtain judicial relief as to each specific remedy granted; Respondent [ ] has been served with notice pursuant to the statute; or [ ] has entered his/her general appearance in this case; or [ ] is in default; or [ ] has filed an answer; That Petitioner has diligently attempted to complete service of process, has not been able to serve the Respondent, and has given notice by publication to the Respondent. FURTHER, THE COURT HAS CONSIDERED ALL THE RELEVANT FACTS, HAS EXAMINED THE PETITION AND PETITIONER, AND FINDS THAT PETITIONER HAS BEEN ABUSED BY RESPONDENT WHO IS A FAMILY OR HOUSEHOLD MEMBER AS DEFINED BY THE ILLINOIS DOMESTIC VIOLENCE ACT, THAT THE PERSONS LISTED HEREINAFTER ARE PROTECTED BY THIS ORDER OF PROTECTION, AND THAT: [] [] [] [] [] [] The abused person is unable to bring this Petition on his/her own behalf due to age, health, disability, or inaccessibility; The Petition is being filed on behalf of an adult with disabilities who has been abused, neglected or exploited by a family or household member. The disclosure of Petitioner's address would risk further abuse. A parent-child relationship [ ] has [ ] has not been established under the Illinois Parentage Act. The court has jurisdiction over the parties and has jurisdiction over the minor child(ren) under the Uniform Child Custody Jurisdiction Act. The parties stipulate to a factual basis for the issuance of an Order of Protection. FURTHER THE COURT HAS, WHERE APPROPRIATE, CONSIDERED THE NATURE, FREQUENCY AND SEVERITY AND EFFECTS OF ANY PAST ABUSE; THE NEGLECT AND EXPLOITATION OF THE PETITIONER OR HOUSEHOLD MEMBER(S) AND HAVING BALANCED THE HARDSHIPS AS REQUIRED, FINDS THERE IS GOOD CAUSE FOR GRANTING OF THE REMEDIES CONTAINED HEREIN AND IT IS HEREBY ORDERED AND DIRECTED THAT: (*) Note: Starred remedies are available only for Interim or Plenary Order (after service on Respondent or entry of appearance by Respondent or counsel) PERSONAL REMEDIES [ ] R01 Respondent is prohibited from harassing, abusing, stalking, intimidating, interfering with personal liberty, willfully depriving, neglecting or exploiting any person protected under this Order or intimidating an dependent. The following persons are protected by this Order: [ ] Petitioner, [ ] minor child(ren), [ ] other household member(s) , [ ] an adult with disabilities: (Police enforced) [ ] R03 Respondent is ordered to stay away from any persons protected under this Order, and not communicated directly or indirectly with persons protected under this Order, whether in person, by telephone, written notes, mail, or through third parties. [ ] Respondent is further prohibited from entering or remaining present [ ] while Petitioner is present at place of employment at during hours of employment from (am/pm) to (am/pm); [ ] while Petitioner and/or minor children are at school grounds located at ; [ ] while any Protected Persons are present at . (Police enforced) 2002 � American LegalNet, Inc. REMEDIES INVOLVING PROPERTY [ ] R02 Respondent is prohibited from entering or remaining present at the residence at , IL because [ ] Petitioner has a right to occupy and Respondent has no such right, or [ ] Petitioner has a right to occupancy and the balance of hardships favors Petitioner's occupancy. [ ] Petitioner [ ] Respondent is allowed access to the residence on , 200__ at (am/pm) in the presence of , who is a person agreed upon by the parties, a law enforcement officer or solely to remove clothing, personal items, medications, and other items as follows: (Police enforced) [ ] R11 Respondent is prohibited from taking, transferring, encumbering, concealing, damaging, or disposing of the following property: , the Court finding that [ ] the property is solely owned by Petitioner, or [ ] the property is jointly owned by the parties, or [ ] Petitioner's sole claim to the property is that it is marital property and a case has been filed in Illinois for Dissolution of Marriage, and the balance of hardships favors possession by Petitioner. . [ ] Respondent is prohibited from using financial or other resources of aged family member, [ ] R10 Petitioner is granted possession of the following personal property: , the Court finding that Petitioner and not Respondent owns the proper