CIRCUIT COURT OF ILLINOIS TWENTY-SECOND JUDICIAL CIRCUIT McHENRY COUNTY Case # Petitioner’s Name (Person desiring protection) Independent Age of Petitioner: Criminal Other Civil Proceeding Address: Juvenile I am filing on behalf of a minor child, dependent, or high risk adult: (file stamp) (Name) (Age) v. Respondent’s Name (Person you desire protection from) VERIFIED PETITION FOR ORDER OF PROTECTION PETITIONER INFORMATION The address listed below is for purpose of service of notice in this case, and is Petitioner’s: Actual address / Alternate Address for Service of Notice because disclosure of abused person’s actual address would risk further abuse. (Street / P.O. Box) (City) (State) (Zip Code) Persons to be included in this Order of Protection, in addition to the Petitioner, are: Full Name Relationship to Petitioner Age RESPONDENT INFORMATION I request an Order of Protection against (Name of Respondent) Date of Birth: / / Social Security Number: __ - Weight: ft. Height: Unknown _- __ Sex: Male in. Hair color: Female Race: Eye color: Page 1 of 10 – Petition (CV-PET1) American LegalNet, Inc. www.FormsWorkflow.com 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.): RELATIONSHIP CODE: The Petitioner/Abused Person stands in relationship to the Respondent as (check all that apply): CODE BG CC GC IL PC PR SC SP XS RELATIONSHIP Boyfriend/Girlfriend (Dating Relationship) Child in Common (parties not married) Grandchild In-Law Personal Assistant or Caregiver to Person with Disability Person Responsible for High-Risk Adult Step-child Step-parent Ex-Former Spouse CODE CH RELATIONSHIP Child CS Shared/common dwelling Grandparent Parent Person with Disability GP PA PD SB SE SS OF Sibling (Brother/Sister) Spouse Step-sibling Other Related by Blood or Marriage Is there or has there ever been an Order of Protection in any jurisdiction naming you as the Yes No Petitioner or Respondent? If yes, what is/was the expiration date? _____ / ______ / _______ If you are/were the Respondent, who is/was the Petitioner? Has the child of any party been designated as either a Respondent or a protected person in Yes No any Order of Protection? If yes, what is/was the expiration date? _____ / ______ / _______ Are there now or have there ever been any civil, criminal, or divorce proceedings involving Yes No None Known you and the Respondent? If yes, please list all pending cases below. Result: 1. Type of Case: Case # (if known) County: Date 2. Type of Case: County: Date Result: Case # (if known) Page 2 of 10 – Petition (CV-PET1) – Revised 12/01/06 American LegalNet, Inc. www.FormsWorkflow.com I am requesting an Order of Protection because on , (Date(s)) at , (City/State) the Respondent did the following things (You may include the relevant history of abuse and its effect(s) on you; attach additional pages, if necessary): the Petitioner resides here the Respondent Venue is appropriate in this county because the abuse occurred here the Petitioner is here temporarily to avoid abuse. resides here Page 3 of 10 – Petition (CV-PET1) – Revised 12/01/06 American LegalNet, Inc. www.FormsWorkflow.com YOU MUST COMPLETE THE FOLLOWING SECTION IF YOU ARE REQUESTING AN EMERGENCY ORDER: I AM REQUESTING AN EMERGENCY ORDER. 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. REMEDIES SECTION (750 ILCS 60/214) PURSUANT TO THE ILLINOIS DOMESTIC VIOLENCE ACT (“THE ACT”), THE PETITIONER SEEKS THE FOLLOWING REMEDIES: A. PERSONAL REMEDIES R01 That Respondent be prohibited from: Harassment, interference with personal liberty, physical abuse, or stalking. Intimidation of a dependent. Willful deprivation. Neglect. Exploitation. R03 That Respondent be ordered to stay away from Petitioner and other protected person(s). That Respondent be prohibited from entering or remaining while Petitioner and/or protected person(s) is/are present at: . . . _____________________________________. Their school(s), located at Any of the following specified places, when Petitioner and/or protected person(s) is/are present: . Their place of residence, currently located at Their place(s) of employment, located at 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. 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. B. PROPERTY REMEDIES R02 That Petitioner be granted exclusive possession of, and Respondent be prohibited from entering or remaining present at the residence/household located at: because: 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 Page 4 of 10 – Petition (CV-PET1) – Revised 12/01/06 American LegalNet, Inc. www.FormsWorkflow.com favors Petitioner’s occupancy over Respondent’s. That Respondent / Petitioner shall have the right to enter the residence – in the presence of law enforcement or an agreed-upon third party, namely ______________________________ - solely to transfer personal property as provided in R10 below. This remedy does not affect title to property (750 ILCS 60/214(b)(2)). R10 That Petitioner be granted the following personal property: That the Respondent be ordered to promptly make available the following property over which the Respondent has possession or control: because: The Petitioner, but not Respondent, owns the property. 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. Petitioner claims property as marital property, and a proceeding has been filed under the Illinois Marriage and Dissolution of Marriage Act (“IMDMA”). Respondent should be given his/her other clothing Personal property should be transferred on personal adornments medicine . at the residence, or at , 20____ at ________(am /pm) in the presence of . R11 That Respondent be prohibited from taking, transferring, encumbering, concealing, damaging, or otherwise disposing of the following real and/or personal property: because: Petitioner, but not Respondent, owns the property; or The Parties own the property jointly, and the balance of hardships favors granting this remedy. Petitioner claims property as marital property and a proceeding has been filed under the IMDMA. Further, 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. C. REMEDIES INVOLVING CHILDREN The primary caretaker of the minor child(ren) is Other Person: Petitioner Respondent (Name and Address) R05 That Petitioner be granted the physical care and possession of the minor child(ren) of the parties, and that: Respondent be ordered to return the minor children to the physical care of: Petitioner Other (Name and Address) Page 5 of 10 – Petition (CV-PET1) – Revised 12/01/06 American LegalNet, Inc. www.FormsWorkflow.com on at a.m. / p.m. in the . presence of Respondent be ordered not to remove the minor child(ren) from the physical care of the Petitioner, school/school grounds, or babysitter/daycare provider. Within 24 hours of the issuance of the Order, the Circuit Clerk is requested to send written notice of the Order to any protected child’s day care or school; specifically, that notice be sent to the following: . R06 (If you desire temporary custody, you should check this box, but this remedy is not available at the Emergency hearing.) That the Court award Petitioner temporary custody of the minor child(ren) of the parties. The children were born prior to or during the course of the marriage between the parties; The parties are unmarried, said children are children in common of the parties and there has / has not been a legal determination of parentage. If neither of the above applies, please explain here: . R07 (Visitation) That the Court: 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). Allow the Respondent to have visitation with the minor child(ren) beginning on from a.m. / p.m. to a.m. / p.m. Each day as follows: a.m./p.m. to Each weekend (Note: a weekend is defined as from a.m./p.m.). a.m./p.m. to Every other weekend (Note: a weekend is defined as from a.m./p.m.). . Other: and a like period thereafter during the pendency of the Order, in addition to the following Holidays: a.m. / p.m. to a.m. / p.m. From Reserve visitation until further hearing. 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. Order the Respondent to pick up and return the child(ren) for visitation at: . (Street Address/City) Order that visitation shall take place at and transportation shall be provided by (Street Address/City) . Page 6 of 10 – Petition (CV-PET1) – Revised 12/01/06 American LegalNet, Inc. www.FormsWorkflow.com be approved to supervise visitation and that I request that such person has filed or will file an affidavit accepting responsibility and acknowledging accountability to the Court. Further, that the Court order Respondent to return the child(ren) to Petitioner or Petitioner’s designated person immediately at the end of visitation. With the provision that Petitioner may deny Respondent access to the minor child(ren) if, when Respondent arrives for visitation, Respondent is under the influence of drugs or alcohol and constitutes a threat to the safety and well-being of Petitioner or Petitioner’s minor child(ren) or is behaving in a violent or abusive manner (750 ILCS 60/214(b)(7)). 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. 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. 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). D. FIREARMS R14.5 The Respondent has threatened to or is likely to use firearms illegally against me. 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 (Type: May be a threat to the safety of the public or police officer when encountered. Is, or has been known to be, suicidal. 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 The Respondent is likely to use firearms illegally against me. [Respondent must be present in court or have had actual notice of these proceedings to obtain this remedy.] The Respondent has the following firearms (describe each): Description Location Page 7 of 10 – Petition (CV-PET1) – Revised 12/01/06 American LegalNet, Inc. www.FormsWorkflow.com E. ECONOMIC REMEDIES R12 (If you desire payment of support, you should check this box, but this remedy is not available at the Emergency hearing.) That the Court order payment of support. Respondent is unemployed / employed by: At (Employer) (Street Address) and has an approximate take-home pay of $ (City/State) . Petitioner requests that Respondent be ordered to pay temporary child support. Petitioner requests that Respondent be ordered to pay temporary support to the Petitioner. R13 (If you desire payment for losses suffered, you should check this box, but this remedy is not available at the Emergency hearing.) That Respondent be ordered to pay Petitioner for losses suffered as a direct result of abuse, neglect, or exploitation, including: Medical expenses Lost earnings Repair/replacement of property damaged or taken Reasonable attorneys’ fees Moving and other travel expenses Reasonable expenses for temporary housing other than a domestic violence shelter/meals Expenses for search and recovery of children Other $ $ (if known) $ $ $ (if known) $ (if known) $ $ (if known) (if known) (if known) (if known) (if known) If you desire payment for any of the above, please bring documentation (receipts, etc.) to the hearing. R16 (If you desire that the Respondent reimburse a shelter, you should check this box, but this remedy is not available at the Emergency hearing.) That Respondent be ordered to reimburse a shelter providing temporary housing or counseling to Petitioner. F. MISCELLANEOUS REMEDIES R04 (If you desire that the Respondent undergo counseling, you should check this box, but this remedy is not available at the Emergency hearing.) That the Respondent be ordered to undergo and successfully complete counseling. R17 That Respondent be further ordered and enjoined as follows: . Page 8 of 10 – Petition (CV-PET1) – Revised 12/01/06 American LegalNet, Inc. www.FormsWorkflow.com 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: _______________________________ Name: Address: City: Phone: State: Zip Code: Fax: . ***SEE DEFINITIONS OF TERMS USED IN THIS PETITION ON THE LAST PAGE (PAGE 10)*** Page 9 of 10 – Petition (CV-PET1) – Revised 12/01/06 American LegalNet, Inc. www.FormsWorkflow.com 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. 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 10 of 10 – Petition (CV-PET1) – Revised 12/01/06 American LegalNet, Inc. www.FormsWorkflow.com