Petition for Relief from Elder Abuse Use this form if you are a "Vulnerable Elder" or if you are filing on behalf of a "Vulnerable Elder." "Vulnerable Elder" means a person 60 years of age or older who is unable to protect himself or herself from elder abuse as a result of age or a mental or physical condition. If filing electronically, you must provide any confidential information in full on a separate form. If filing in paper, you must provide any confidential information in full on a separate form. If you do not understand how to use this form, talk to an attorney. In the Iowa District Court for County County where you are filing this Petition Civil no. Plaintiff or Substitute Petitioner Full name of person filing Petition For clerk use only vs. Petition for Relief from Elder Abuse Iowa Code chapter 235F Defendant(s) Full name of Defendant(s) If you need assistance to participate in court due to a disability, call the disability coordinator at _________________. Persons who are hearing or speech impaired may call Relay Iowa TTY (1-800-7352942). Disability coordinators cannot provide legal advice. Disability coordinator contact information available at: http://www.iowacourts.gov/Administration/Directories/ADA_Access/. 1. I, Full name , am filing as: Check A or B, provide requested information. A. Plaintiff (1) I, Plaintiff, live in County, Iowa. (2) I can receive mail at the following address: Any of the following addresses may be used: your mailing address, the mailing address of a shelter or other agency, a public or private post office box, or any other mailing address with permission of the resident of that address. ____________________________ Plaintiff's mailing address _____________ _______ City State ___________ ZIP code ____________ County (3) My year of birth: B. Substitute Petitioner (1) (2) I, Substitute Petitioner, live in County, Iowa. I can receive mail at the following address: Any of the following addresses may be used: your mailing address, a public or private post office box, or any other mailing address with permission of the resident of that address. ____________________________ Substitute Petitioner's mailing address _____________ _______ City State ___________ ZIP code ____________ County March 2015 Petition for Relief from Elder Abuse Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Petition for Relief from Elder Abuse, continued 3) I am filing this Petition for Relief from Elder Abuse on behalf of: a. Elder's full name: b. Elder's year of birth: yyyy c. Elder's mailing address: Any of the following addresses may be used: Elder's mailing address, the mailing address of a shelter or other agency, a public or private post office box, or any other mailing address with permission of the resident of that address. ____________________________ Elder's mailing address _____________ _______ City State ___________ ZIP code ____________ County Note: If a Substitute Petitioner files the Petition, the Elder upon whose behalf the Petition is filed maintains the following rights: � To cross-examine witnesses at the hearing. � To request a hearing on the Petition. � To present evidence. � To contact and retain counsel. � To have access to personal records. � To file objections to the protective order. 2. Defendant lives at the following address (if known): ________________ Address City State ZIP code County Note: If more than one Defendant, attach additional sheets for items 2, 3, and 4. 3. Defendant is employed at the following (if known): Employer ________________ Mailing Address City State ZIP code County 4. Defendant is 17 years of age or younger: If yes, provide Defendant's year of birth: yyyy Yes No Do not know 5. Give the name and age of other individuals whose welfare may be affected by alleged elder abuse: Attach additional sheets if necessary Name Birth year Name Birth year Provide only initials if minor Provide only initials if minor (1) (2) (3) (4) March 2015 Petition for Relief from Elder Abuse Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Rule 235--Form 1Petition for Relief from Elder Abuse, continued 6. Relationship of Elder and Defendant(s) at the time of the alleged elder abuse: Check all that apply A. Married B. Separated C. Divorced D. Living together E. Intimate relationship F. Relative or household member G. Caretaker H. Fiduciary Includes attorney, guardian, or conservator I. Other: 7. Nature of the alleged elder abuse: Check all that apply A. Physical injury B. Sexual abuse C. Neglect D. Financial exploitation E. Recently threatened F. Other: 8. Describe the alleged abuse or threats of abuse inflicted on the Elder. Identify who inflicted the alleged abuse or threats of abuse, and please include how the Elder was allegedly hurt or threatened, where it happened, when it happened, and the likelihood that the alleged abuse or threats will occur in the future. 9. I am asking the court to do the following: Check A or B or both A. Enter an Emergency Protective Order/Temporary Protective Order. Issue an Emergency or a Temporary Protective Order immediately to protect the Elder before the hearing on this Petition because the Elder is in present danger of elder abuse. B. Enter a Protective Order on this Petition. March 2015 Petition for Relief from Elder Abuse Page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Petition for Relief from Elder Abuse, continued 10. I request that the court order Defendant(s) to: Check each that is requested A. Stop the elder abuse. B. Move from the Elder's residence. � � I may request that a law enforcement officer accompany Defendant(s) when leaving the residence; or If Defendant(s) has or have already left the residence, I may request that a law enforcement officer accompany Defendant(s) while removing essential personal effects of Defendant(s) from the residence. C. Provide suitable alternative housing for the Elder. � � I may request that a law enforcement officer accompany the Elder who is leaving the residence; or If the Elder has already left the residence, I may request that a law enforcement officer accompany the Elder to remove essential personal effects from the residence. D. Be restrained from entering or attempting to enter the following locations at the following times: Attach additional sheets if necessary Name of location, mailing address, street, city, IA, Zip code, time of day (xx:xx AM/PM) E. Be restrained from exercising any powers on behalf of the Elder through a court-appoi