PETITION FOR RESTRAINING ORDER TO PREVENT ABUSE OF ELDERLY PERSON OR PERSON WITH DISABILITIES - Page 1 of 4 (EPPDAPA 8/2016) IN THE CIRCUIT COURT OF THE STATE OF OREGON COUNTY OF (See CIF) ) Petitioner (date of birth) ) (name of person to be protected) ) PETITION FOR RESTRAINING ORDER ) TO PREVENT ABUSE OF ELDERLY by and through his/her Guardian Petitioner: ) PERSON OR PERSON WITH DISABILITIES ) (name of Guardian Petitioner) ) v. ) Case No. ) (See CIF) ) Respondent (date of birth) )(person to be restrained) ) (Check one): I am the Petitioner and reside in County, state of . I state that the information provided below is true: or I am the Guardian Petitioner. The elderly person or person with disabilities on whose behalf I am filing this petition is (Name) who is a resident of County, state of . I am the guardian guardian ad litem for the named elderly person or person with disabilities. I state that the information provided below is true: Respondent is a resident of County, state of GUARDIAN PETITIONERS : THROUGHOUT THIS FORM, INFORMATION IS PROVIDED FOR AND REQUESTED ABOUT THE ELDERLY OR DISABLED PERSON YOU REPRESENT. AS A GUARDIAN PETITIONER , YOU ARE TO PROVIDE INFORMATION, NOT ABOUT YOURSELF , BUT ABOUT THE ELDERLY OR DISABLED PERSON ON WHOSE BEHALF YOU ARE SEEKING A RESTRAINING ORDER. Provide information about yourself as 223guardian petitioner224 only where specifically requested. NOTICE TO PETITIONER You must provide complete and truthful information. If you do not, the court may dismiss any restraining order and may also hold you in contempt. Contact Address : If you wish to have your residential address or telephone number withheld from Respondent, use a contact address and telephone number so the court and the sheriff can reach you if necessary. American LegalNet, Inc. www.FormsWorkFlow.com PETITION FOR RESTRAINING ORDER TO PREVENT ABUSE OF ELDERLY PERSON OR PERSON WITH DISABILITIES - Page 2 of 4 (EPPDAPA 8/2016) Check and fill out the section that applies to you : I am 65 years of age or older. I am years of age. I am a person with disabilities. Explain the nature of the mental or physical disability: 1. CHECK AND FILL ANY SECTION(S) that apply to you and respondent. A. Respondent and I have been living together since . (date) B. Respondent and I lived together from to . (date) (date) C. I have been under the care of respondent since . (date) D. I was under the care of respondent from to . (date) (date) E. None of the above. 2. To qualify for a restraining order, respondent must have done one or more of the following. Within the last 180 days, respondent has : A. Caused me physical injury by other than accidental means. B. Attempted to cause me physical injury by other than accidental means. C. Placed me in fear of immediate serious physical injury. D. Caused me physical harm by withholding services necessary to maintain my health and well- being. E. Abandoned or deserted me by withdrawing or neglecting to perform duties and obligations. F. Willfully inflicted me with physical pain or injury. G. Used derogatory or inappropriate names, phrases or profanity, ridicule, harassment, coercion, threats, cursing, intimidation or inappropriate sexual comments or conduct of such a nature as to place me in fear of significant physical or emotional harm. H. Wrongfully taken or appropriated my money or property, or alarmed me by conveying a threat to me that my money or property would be wrongfully taken or appropriated, which threat I reasonably believed would be carried out. I. Had nonconsensual sexual contact with me or sexual contact to which I was incapable of consenting. 3. Any period of time after the abuse occurred during which respondent was incarcerated (in jail or prison) or lived more than 100 miles from your home is not counted as part of the 180-day period, and you may still be eligible for a restraining order. Respondent was incarcerated from (date) to (date). Respondent lived more than 100 miles from my home from (date) to (date). 4. Did the abuse happen within the last 180 days not including the times Respondent was incarcerated (in jail or prison) or lived more than 100 miles from your home? Yes No (Check one) Date and location of abuse: American LegalNet, Inc. www.FormsWorkFlow.com PETITION FOR RESTRAINING ORDER TO PREVENT ABUSE OF ELDERLY PERSON OR PERSON WITH DISABILITIES - Page 3 of 4 (EPPDAPA 8/2016) How did respondent injure or threaten to injure you? 5. Are there incidents other than those described in question 4 above in which respondent injured or threatened to injure you? If yes, explain: 6. I am in immediate and present danger of further abuse by respondent because: 7. In any of the above incidents: Were drugs, alcohol, or weapons involved? Yes No (Check one) Did you need medical help? Yes No (Check one) Were the police or the courts involved? Yes No (Check one) If you have checked yes to any of the above questions, explain: 8. A. There is is not another Elderly Persons and Persons With Disabilities Abuse Prevention Act, Family Abuse Prevention Act, or Stalking Order proceeding pending between respondent and me. It is filed in County, State of , and I am the Petitioner Respondent in that case (check one). The case number of the case is: B. There is is not another lawsuit pending between respondent and me for divorce, annulment, or legal separation. If yes, type of lawsuit: . It is filed in County, State of . C. There is is not a guardianship, conservatorship, or other protective proceeding pending in which either the respondent or I is a party. If yes, type of lawsuit: . It is filed in County, State of . 9. Respondent may be required to move from your residence if: (a) it is in your sole name; (b) if it is jointly owned or rented by you and Respondent; or (c) if you and Respondent are married. I do do not want Respondent to move from my residence. My residence is: Owned Leased Rented by: (name). American LegalNet, Inc. www.FormsWorkFlow.com PETITION FOR RESTRAINING ORDER TO PREVENT ABUSE OF ELDERLY PERSON OR PERSON WITH DISABILITIES - Page 4 of 4 (EPPDAPA 8/2016) PETITIONER/GUARDIAN PETITIONER ASKS THE COURT TO ORDER HIS/HER REQUESTS AS MARKED ON THE ATTACHED RESTRAINING ORDER. PETITIONER/GUARDIAN PETITIONER MUST NOTIFY THE COURT OF ANY CHANGE OF ADDRESS. ALL NOTICES OF HEARING WILL BE SENT TO THIS ADDRESS AND DISMISSALS MAY BE ENTERED IF THE PETITIONING PARTIES DO NOT APPEAR AT A SCHEDULED HEARING. If you wish to have a residential address or telephone number withheld from respondent, use a contact address and contact telephone number so the court and the sheriff can reach you if necessary. I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and subject to penalty for perjury. Date: Signature of Petitioner Guardian Petitioner Print or Type Name of Petitioner Guardian Petitioner Certificate of Document Preparation You are required to truthfully complete this certificate regarding the document you are filing with the court. Check all boxes and complete all blanks that apply: I selected this document for myself and I completed it without paid assistance. I paid or will pay money to for assistance in preparing this form. Submitted by: Print Name, Petitioner Guardian Petitioner Attorney for Petitioner/Guardian Petitioner OSB No. (if applicable) Address or Contact Address City, State, Zip Telephone or Contact Telephone Number Use safe contact address Use safe contact number If you wish to have your residential address or telephone number withheld from Respondent, use a contact address or telephone number so the Court and the Sheriff can reach you if necessary. American LegalNet, Inc. www.FormsWorkFlow.com