PROBATE COURT OF ___________________________COUNTY, OHIO _____________________, JUDGE IN THE MATTER OF __________________________________________, AN ADULT CASE NO. _______________________ PETITION FOR TEMPORARY RESTRAINING ORDER TO PREVENT INTERFERENCE WITH INVESTIGATION OF REPORTED ABUSE OF AN ADULT [R.C. 5101.63] 1. Petitioner, _____________________________, is an authorized provider of adult protective services pursuant to R.C. 5101.60, et seq. and has received a report that the above named Adult is in need of protective services. 2. The Adult, _____________________________, residing at _______________________ ____________________________is ________years of age, with a date of birth of ___________ and is alleged to be an incapacitated person subject to abuse, neglect, or exploitation. 3. The Respondent (Name and Address):_________________________________________ ______________________________________________________________________________ denied or obstructed access by Petitioner to the residence of the Adult. 4. Unless Respondent is restrained, Petitioner will be unable to perform its duty to investigate the report as mandated by R.C. 5101.62. 5. An Affidavit setting forth the facts to support this petition is attached. WHEREFORE, the Petitioner requests the Court to issue an order restraining Respondent from obstructing or in any way interfering with Petitioner’s access to the residence of the Adult and further ordering access to the Adult by any Peace Officer requesting to accompany the Petitioner. ______________________County Department of Job and Family Services _______________________________ By:_________________________________ Attorney _______________________________ ____________________________________ Address Title _______________________________ ____________________________________ Address _______________________________ ____________________________________ Phone Number (including area code) _______________________________ ____________________________________ Registration No. Phone Number (including area code) _______________________________ ____________________________________ E-mail E-mail FORM 23.4 – PETITION FOR TEMPORARY RESTRAINING ORDER TO PREVENT INTERFERENCE WITH INVESTIGATION OF REPORTED ABUSE OF AN ADULT Eff. Date: January 1, 2010 American LegalNet, Inc. www.FormsWorkFlow.com