CIRCUIT COURT OF ILLINOIS Independent TH 15 JUDICIAL CIRCUIT Criminal STEPHENSON COUNTY Juvenile Other Civil Proceeding Case # Petitioners Name (Person desiring Protection) I am filing on behalf of : myself minor child(ren) dependent high risk adult: (Full Name) (Age) V. Respondents 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 Petitioners 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 persons 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) Unknown Social Security Number: Sex: Male Female Race: Weight: Height: ft. in. Hair color: Eye color: Respondents Current Address: (Street/P.O. Box) (City) (State) (Zip Code) Respondents Work Address: (Street/P.O. Box) (City) (State) (Zip Code) 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>>>> 2RELATIONSHIP 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) (SB ) In-Law (IL) Boyfriend/Girlfriend (BG) Step-child (SC ) Person with Disability (PD) (Dating Relationship) Child in Common (CC ) Step-sibling (SS ) Person Responsible for High- (parties not married) Risk Adult (PR ) Shared/common dwelling (CS ) Step-parent (SP ) Personal Assistant or 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 St/County Case Date of Expiration Respondent Number (mmddyyyy) 2. Has a child/dependant/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 St/County Case Date of Expiration Respondent Number (mmddyyyy) 3. Are there now, or have there ever been, any civil, 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: State/County Case # (if known) Date: b. Type of Case: Result: State/County Case # (if known) Date: c. Type of Case: Result: State/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 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>>>> 4 REMEDIES SECTION (750 ILCS 60/214) PURSUANT TO THE ILLINOIS DOMESTIC VIOLENCE ACT (THE ACT), THE PETITIONER SEEKS THE FOLLOWING REMEDIES: PART A. REMEDIES INVOLV ING PERSONAL PROTECTION 1. (RO1) 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. (RO3) That Respondent be ordered to stay away from Petitioner and other protected person(s). a. That the Respondent be ordered to stay ft. away from Petitioner and other protected person(s). b. That the Respondent is or dered to stay ft. away from the residence of Petitioner and/or other protected person(s), currently located at 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 Petitioners children. Page 4 of 11 - Petition American LegalNet, Inc. www.USCourtForms.com>>>> 5PART B. REMEDIES INVOLVING PROPERTY (These remedies do not affect title to property (750 ILSC 60/214(b)(2)). 1. (RO2) 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 t