CIRCUIT COURT OF ILLINOIS Indepe ndent JUDICIAL CIRCUIT Criminal Ju venile COUNTY Other Civil Proceed ing C ase # Petition e rs Name (Person desiring protection) I am f iling on beh alf of: m yse lf minor child(ren) dependent high risk adul t: ( file st am p) (Full Name) (Age) v. Res p on de nts Nam e (Person you desire protection from) VERIF I ED PET I TION FOR ORDER OF PROTECTION I reque st a n Order of Prote ction a ga inst . ( Nam e of Respondent ) I am requesting an Eme rge ncy Order of Protection. I did not give the Respo ndent notic e that I am seeking prot ection beca use I fear t hat gi ving notice would resul t in further ab us e or becaus e the abuse is likely to recur befor e I return to court. Good cause e xists for gran ting t he remedy or remedies re quested without prior service of p rocess or notice. PETITIONER INF O RMATI ON The Petitioners address for the pu rpose of ser vice of notice is: ( S treet / P.O. Box) ( City) ( S tate) ( Zip Code) Check th is box, if the abov e address is an Alternate Addr ess for Service of Notice because disclosure o f abused pe rsons actual address would risk fur t her abuse. Persons to be included in the Order of Prot ection, in additi on to the Pet itioner, are: Fu ll N am e Age St at e of Res id en ce Rel ati o n ship to Pe tit io n er RESPONDENT INFORMATION Dat e o f Bir t h : ______ ________ (mmddyyyy) Unknown Soci a l Sec u rity Nu mber : Sex : Male Femal e Rac e : Weight : Heig ht : ft. in. Hair c olor : Ey e co lo r : Res p on de nts Curre nt Addre s s : (S treet / P.O. Box) ( City) ( S tate) ( Zip Code) Respondents Work Address : (S treet / P.O. Box) ( City) ( S tate) ( Zip Code) Distin guis hing Featu r es (scars, marks, tattoos, etc.) : Form approved by the Conference of Chief Circuit Judges Effective November 1, 2004 American LegalNet, Inc.Use required after July 1, 2005 Page 1 of 11 Petition www.USCourtForms.com>>>> 2RELATIONSHIP CODE The Petitioner/Abused Person stands in the following relationship to the Respondent (check all that apply): 9 RELATIONSHIP 9 RELATIONSHIP 9 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 (Dating Relationship) (PD ) Child in Common ( CC ) Step-sibling ( SS ) Person Responsible for (parties not married) High-Risk Adult ( PR ) 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: Date of expiration Name of Petitioner Name of Respondent St/County Case Number (mmddyyyy) 2. Has a child/dependent/high risk adult of either party b een designated as either a Respondent or protected person in any other Order of Protection, Custody or Guar dianship proceeding? Yes No If yes , please provide the following information for each Order: Date of expiration Name of Petitioner Name of Respondent St/County Case Number (mmddyyyy) 3. Are there now, or have there ever been, any ci vil, criminal, or divorce proceedings involving you, one of the protected person s and/or the Respondent? Yes No None Known If yes, please list all pending cases below. a . Type of Case: Result: S tate/County: Case # (if known) Date b . Type of Case: Result: S tate/County: Case # (if known) Date c . Type of Case: Result: S tate/County: 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 >>>> 35. I am requesting an Order of Pr otection because the Re spondent did the following things o n the dates and times indicated below. (Be Sp ecific ) (Include the relevant history of abuse, the effect the abuse had on you, and the date and pla ce that each i ncident occur r ed. Attach additiona l pages, if necess ary ) Dat e (s ) Descri ptio n of Incid e nt(s) Continue d on attac hed page(s) Page 3 of 11 Petition American LegalNet, Inc. www.USCourtForms.com >>>> 4 REMEDIES SECTION (750 ILCS 60/ 214) PURSUAN T TO THE ILLINOIS DOMEST IC VIOLENCE ACT (T HE ACT), THE PETITION ER SEEKS THE FOLLOWING REMEDIE S: PART A. REMEDIES INVOLVING P ERSONA L PROTE CTION 1. (R01) With respect to al l protected persons, tha t t he Respond e nt be pro hibited from commi tting the fol lowing acts of abuse or threats of abuse (check all that apply): Harassm ent, interference with personal liberty, physical abuse, or stalking. In timidation of a dependent. Willful deprivat ion. Neglect. Exploitation. 2. (R03) That Resp ondent be o rdered to stay away fro m Petitioner and o t her protected person(s). a. Tha t the Respond ent be orde red to sta y ft. awa y from Peti tioner and other protected person(s). b. That the Respond ent is ordered to sta y ft. awa y from the resi dence of Petitioner and/or other prote cted person(s), currently located at . c. That Respondent be ordered not to c o mmunic a t e in any way dir e ct ly, indir e ct ly, or throu g h th ird parties - with Pet itioner an d/or other prot ected pers ons, i n cludin g, but not li mited to ph on e, written n o tes, mail, email, or fax. d. That R e spondent be prohibited from ente ring or remain ing while Pet itioner an d/or protected p e rson(s) is/are present at: Their place of residence, curren tly locate d at . Their place(s) of empl oyment, located at . Their day care / s chool(s), l ocated at . Any of the following specified places, when Petitioner and/or prot ected person (s) i s/are prese nt : . 3. (R14) That Resp ondent be prohibit ed from en tering or remaining in the re sidence or househol d while under the influen ce of drugs or al cohol and co nsti tut ing a t hreat to t he safe t y or well-being of Peti tioner or Petiti oners children. Page 4 of 11 Petition American LegalNet, Inc. www.USCourtForms.com >>>> 5PART B . REMEDIES INVOLVING P R OPERTY (These remedies do not affec t t itl e to prope r ty (7 50 ILC S 60 / 214(b ) ( 2 ) ) . 1. (R02) That the Petiti oner