STATE OF SOUTH DAKOTA COUNTY OF ________________ ) ) ) IN ______________________ COURT ___________________ JUDICIAL CIRCUIT Petitioner, -vsTPO NO. __________________________ PETITION AND AFFIDAVIT FOR A PROTECTION ORDER (VULNERABLE ADULT) Respondent. I,_____________________________________, being duly sworn upon oath, state and affirm the following: I am: (check one) the Petitioner filing on behalf of the Petitioner (as the "Substitute Petitioner"), and my relationship to the Petitioner is: (describe) The Petitioner is a vulnerable adult because the Petitioner is: (check one) a person sixty-five years of age or older who is unable to protect himself or herself a person eighteen years of age or older who cannot protect himself or herself, or provide for his or her own care, because of one of the following conditions: · an intellectual disability; · infirmities of aging as manifested by organic brain damage; · advanced age; or · other physical dysfunctioning. The Petitioner is, or the Respondent is, a South Dakota resident. Petitioner resides in County, Respondent resides in County, (state); (state). The Respondent is: (check all that apply) Petitioner's family member (describe Respondent's relation): Petitioner's agent under a power of attorney Petitioner's guardian Petitioner's conservator Petitioner's caretaker (a person who assumed responsibility for Petitioner's health and welfare) a person who was entrusted with Petitioner's property a person in whose integrity and truthfulness Petitioner placed trust and confidence (for this last choice, please describe below Respondent's confidential relationship to Petitioner): 1 Form UJS-120A (Vulnerable Adult) Petition Rev. 6/16 American LegalNet, Inc. www.FormsWorkFlow.com I AM ASKING THE COURT FOR A PROTECTION ORDER BASED UPON THE FACTS BELOW: Starting or occurring on or about (month) (day) (year) at approximately o'clock (am/pm), the Respondent committed the following act(s) of vulnerable adult abuse against the Petitioner: (check any that apply) Respondent caused Petitioner physical harm or bodily injury. Respondent attempted to cause Petitioner physical harm or bodily injury. Respondent caused Petitioner fear of imminent physical harm or bodily injury. Respondent was Petitioner's caretaker or was entrusted with Petitioner's property at the time and neglected Petitioner's health or welfare without medical justification and within Petitioner's means. Respondent was Petitioner's family member, Petitioner's caretaker, or a person in whom Petitioner placed trust and confidence at the time Respondent defrauded and/or stole Petitioner's property. Respondent was Petitioner's caretaker or was entrusted with Petitioner's property during the time Respondent repeatedly and without Petitioner's consent directed obscene sexual acts or simulated sexual acts at Petitioner (detail the number of instances, dates and times below). Respondent was Petitioner's caretaker or was entrusted with Petitioner's property during the time Respondent repeatedly and unreasonably confined Petitioner (detail the number of instances, dates and times below). Respondent was Petitioner's caretaker or was entrusted with Petitioner's property during the time Respondent willfully, maliciously, and repeatedly harmed, damaged or destroyed Petitioner's property (detail the number of instances, dates and times below). Respondent was Petitioner's caretaker or was entrusted with Petitioner's property during the time Respondent willfully, maliciously, and repeatedly ridiculed, demeaned, verbally harassed, or threatened Petitioner (detail the nature, dates, and times of these incidents below). Provide a detailed description of what happened on the above date(s): 2 Form UJS-120A (Vulnerable Adult) Petition Rev. 6/16 American LegalNet, Inc. www.FormsWorkFlow.com Yes Yes Yes Yes No No No No Don't Know Don't Know Don't Know Don't Know Yes No Don't Know Yes Yes Yes No No No Don't Know Don't Know Don't Know Was law enforcement called during this incident (or these incidents)? Was Respondent arrested for this incident (or incidents)? Is Respondent in jail? Has Respondent violated previous protection orders? If so, against whom Give the date of the violation and the county and state of the violation Has Respondent been found guilty of violating previous protection orders? If so, against whom Give the date of the conviction and the county and state of the conviction Does Respondent possess guns or weapons? Was a weapon used in this incident (or these incidents)? Has Respondent threatened anyone with a weapon? Provide a detailed description of other similar incidents or actions that Respondent has committed and reasons you believe it will continue: 3 Form UJS-120A (Vulnerable Adult) Petition Rev. 6/16 American LegalNet, Inc. www.FormsWorkFlow.com REQUEST FOR HEARING AND PROTECTION ORDER Based upon this Petition and Affidavit in which I truthfully set forth the details of the vulnerable adult abuse, I respectfully ask the Court to set a date to hear this matter and after hearing the evidence, to grant Petitioner a Protection Order: 1) To restrain Respondent from acts of vulnerable adult abuse. 2) To grant the Protection Order for a period of time (no longer than 5 years). 3A)To exclude Respondent from Petitioner's residence listed in 4B, OR B)To require Respondent provide Petitioner with suitable alternative housing. 4) To order that Respondent shall not come within a distance of from the following persons and places: A. Petitioner personally B. Petitioner's residence (street/apt) (city) , (state) (zip) C. Petitioner's place of employment (street) (city) , (state) (zip) D. Other places (street/apt) (city) , (state) (zip) (street/apt) (city) , (state) (zip) (street/apt) (city) , (state) (zip) 5) To restrain Respondent from exercising any fiduciary powers on Petitioner's behalf through a courtappointed guardian, conservator, guardian ad litem, agent, or another third party. 6) To require a peace officer accompany the party who is leaving or has left the residence while that party is removing essential personal effects. 7) That the Respondent be restrained from contact with Petitioner by any direct or indirect means except as authorized by a court order. 8) To Order other relief which I believe is necessary for the safety and welfare of Petitioner: 9) Where Petitioner was the victim of financial exploitation: A. To direct Respondent to refrain from exercising control over Petitioner's funds