RESTRAINING ORDER TO PREVENT ABUSE - Page 1 of 5 (EPPDAPA 8/2016) IN THE CIRCUIT COURT OF THE STATE OF OREGON COUNTY OF ) Petitioner (Date of Birth) ) (name of person to be protected) ) RESTRAINING ORDER ) TO PREVENT ABUSE by and through his/her Guardian Petitioner: ) (Elderly Persons and Persons With Disabilities ) Abuse Prevention Act) (name of Guardian Petitioner) ) ) Case No. v. ) (See CIF) ) Respondent (Date of Birth) )(person to be restrained) ) The court, having reviewed the petition, makes the following findings: JUDGE222S INITIALS A. The Protected Person is Petitioner (name of person to be protected) A. and has been abused by the Respondent as defined by ORS 124.005; B. The abuse of the Protected Person by the Respondent occurred within the last 180 days B. as provided in ORS 124.010; C. The Protected Person is in immediate danger of further abuse. C. IT IS HEREBY ORDERED that: Petitioner222s/Guardian Petitioner222s Request 1. Respondent is restrained (prohibited) from abusing, intimidating, molesting, 1. interfering with, or menacing the Protected Person, or attempting to abuse, intimidate, molest, interfere with or menace the Protected Person. NOTICE TO THE RESPONDENT: You must obey all of the provisions of this Restraining Order, even if the Petitioner contacts you or gives you permission to contact him/ her. Violation of this Restraining Order may result in your arrest and in civil and/or criminal penalties. This order is enforceable throughout Oregon and in every other state. Review this order carefully. See the attached 223NOTICE TO RESPONDENT/REQUEST FOR HEARING224 for more information about your rights to a hearing. (See CIF) American LegalNet, Inc. www.FormsWorkFlow.com RESTRAINING ORDER TO PREVENT ABUSE - Page 2 of 5 (EPPDAPA 8/2016) JUDGE222S INITIALS 2. Respondent is restrained (prohibited) from entering or attempting to enter or be 2. within feet of the following locations: (Include names and address unless withheld for safety reasons.) The Protected Person222s residence, The Protected Person222s business or place of employment, The Protected Person222s school, Other locations: 3. Respondent is restrained (prohibited) from: 3. Contacting, or attempting to contact the Protected Person by telephone. Contacting, or attempting to contact the Protected Person by mail. Coming, or staying within 150 feet or feet of the Protected Person. 4. Respondent shall move from and not return to the residence located at: 4. except with a peace officer in order to remove essential personal effects of the Respondent, including, but not limited to: clothing, toiletries, medications, social security cards, birth certificates, identification, and tools of the trade. 5. A peace officer shall accompany the Protected Person, or his/her Guardian Petitioner 5. to the parties222 residence in order to remove essential personal effects including, but not limited to: clothing, toiletries, medications, social security cards, birth certificates, identification, and tools of the trade. 6. The Protected Person has been a victim of abuse involving the wrongful taking or 6. appropriation of money or property. To prevent or remedy the wrongful taking or appropriation the following order(s) is/are made: a. The Respondent shall refrain from exercising control over the money or 6a. property of the elderly or disabled person. (Optional) The money or property that the Respondent is prohibited from exercising control over is as follows: Nothing in this restraining order prevents Respondent from appearing at or participating in a court (or administrative) heari ng or other related legal process as a party or witness in a case involving the Petitioner. At these times, Respondent must stay at least feet away from the Petitioner and follow any additional protective terms ordered in that case. Further, nothing in this order prevents Respondent from serving or providing documents related to a court (or administrative) case to the Petitioner in a manner permitted by law. However, Respondent may not personally deliver legally-related documents to the Petitione r. American LegalNet, Inc. www.FormsWorkFlow.com RESTRAINING ORDER TO PREVENT ABUSE - Page 3 of 5 (EPPDAPA 8/2016) b. The Respondent is required to return custody or control of the money or 6b. property of the elderly/disabled person to the elderly/disabled person. (Optional) The money or property to be returned is as follows: c. The Respondent is required to follow the instructions of the guardian or 6c. conservator of the elderly or disabled person. d. The Respondent is prohibited from transferring the money or property of the 6d. elderly or disabled person to any person other than the elderly or disabled person. e. Other (optional/See NOTE below): 6e. Judge222s Initials 7. Other relief: 7. 8. No further service is necessary because Respondent appeared in person before the 8. court. IT IS FURTHER ORDERED that the SECURITY AMOUNT for violation of any provision of this Order is $5,000 unless otherwise specified here: Other Amount: $ . IT IS HEREBY ORDERED that: The Petition for Restraining Order to Prevent Abuse of Elderly Person or Person with Disabilities is: Granted Denied because: DATED this day of , 20 . Judge Signature: NOTE : 223Other224 relief under Paragraph 6 to prevent or remedy the wrongful taking or appropriation of money or property CANNOT allow any person other than the elderly or disabled person to assume responsibility for managing the elderly or disabled perso n222s money or property, and relief cannot be granted that is more appropriately obtained in a protective proceeding filed under ORS chapter 125. [ORS 124.020(2)(a)] The above provisions of this Restraining Order to Prevent Abuse of Elderly Person or Perso n with Disabilities are in effect for a period of one (1) year from the date of the judge222s signature (unless renewed before it expires) or until the Order is vacated, modified, or superseded, whichever occurs first. American LegalNet, Inc. www.FormsWorkFlow.com RESTRAINING ORDER TO PREVENT ABUSE - Page 4 of 5 (EPPDAPA 8/2016) Certificate of Document Preparation and Readiness for Judicial Signature. 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. This proposed order is ready for judicial signature under UTCR 5.100 because this order is submitted ex parte as allowed by statute or rule. Dated: Submitted by (signature): Print Name, Petitioner Attorney for Petitioner OSB No. (if applicable) Address or Contact Address City, State, Zip Telephone or Contact Telephone Number Use a Safe Contact address Use a Safe Contact number // // // // // // // // // // American LegalNet, Inc. www.FormsWorkFlow.com RESTRAINING ORDER TO PREVENT ABUSE - Page 5 of 5 (EPPDAPA 8/2016) RELEVANT DATA Protected Person: Female Male Name ***Residence/Contact Address (Use a safe address***): Number, Street and Apt. Number (if applicable) City County State Zip Telephone/Contact Telephone Number (Use safe contact number) Birthdate (See CIF) Age Race/Ethnicity Height Weight Eye Color Hair Color RESPONDENT: Female Male Name Residence Address Telephone Number Birthdate (See CIF) Age Race/Ethnicity Height Weight Eye Color Hair Color PLEASE FILL OUT THIS INFORMATION TO AID IN SERVICE OF THE RESTRAINING ORDER Where is Other Party most likely to be located? Residence Hours Address Employment Hours Address (See CIF) Other Hours Address Description of Vehicle Is there anything about the other party222s character, past behavior, or the present situation that indicates that he or she may be a danger to others? to him/herself? EXPLAIN: Does the other party have any weapons, or access to weapons? EXPLAIN: Has the other party ever been arrested for or convicted of a violent crime? EXPLAIN: ***The Respondent will receive a copy of this information. If you wish to have your residential address or telephone number withheld from Respondent, use a contact address in the state wher