CV-428, 05/19 Petition for Temporary Restraining Order and/or Petition and Motion for Injunction Hearing (Individual at Risk) 247813.123, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 3 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Petitioner : (Individual at Risk) Amended Petition for Temporary Restraining Order and/or Petition and Motion for Injunction Hearing ( Individual at Risk - 30713) Case No. Date of Birth: Name of person completing Petition: (if different from Individual at Risk) - vs - Respondent/ Defendant: Address: x-none : Sex Race Date of Birth Height Weight Hair color Eye color Please specify rela tionship(s) to Respondent: spouse cousin adoptive parent former spouse sibling grandpa rent person in dating relationship parent child (biological/adoptive/step) current or former live - in step parent relationship O ther: [B e specific ] Distinguishing Features: (such as scars, marks or tattoos) None k nown. CAUTION: (Check all that apply) Respondent has access to weapon(s). Type of weapon(s): Location of weapon(s ): Weapon(s) were involved in an incident [ past or present ] involving the individual at risk. I am: [Check one] an individual at risk. a person acting on behalf of an individual at risk. a representative of an adult - at - risk agency, or an elder - adult - at - risk agency. I PETITION THE COURT for a T emporary Restraining Order and/or I njunction against the respondent under 247813.123, Wis. Stats., based on the following: 1. The individual at risk is [Check one] a. an adult at risk (an adult who has a physical or mental condition that substantially impairs his/her ability to care for his/her needs and who has experienced, is currently experiencing, or is at risk of experiencing physical abuse, emotional abuse, sexual abuse, treatment without consent, unreasonable confinement or restraint, neglect, self - neglect, or financial exploitation). b. an elder adult at risk (a person age 60 or older who has experienced, is currently experiencing, or is at risk of experiencing physical abuse, emotional abuse, sexual abuse, treatment without consent, unreasonable confinement or restraint, neglect, self - neglect, or financial exploitation). 2. The adult respondent has [M ark any of the following boxes that apply ] a. interfered with, or based upon prior conduct of the respondent, may interfere with 1. an investigation of the individual at risk; or 2. the delivery of protective services to the individual at ris k; or 3. the delivery of protective placement to the individual at risk; or 4. the delivery of services to the elder adult at risk, and that the interference complained of, if continued, would make it difficult to determine whether physical abuse, emotional abuse, sex ual abuse, treatment without consent, unreasonable confinement or restraint, financial exploitation, neglect, or self - neglect has occurred, is occurring, or may recur. OR b. engaged in or threatened to engage in with the individual at r isk physical abuse. emotional abuse. sexual abuse. treatment without consent. financial exploitation. unreasonable confinement or restraint. neglect. harassment. American LegalNet, Inc. www.FormsWorkFlow.com CV-428, 05/19 Petition for Temporary Restraining Order and/or Petition and Motion for Injunction Hearing (Individual at Risk) 247813.123, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 3 stalking. mistreatment of an animal. 3. Stated bel ow or attached as part of this P etition is a statement of facts i ndicating that respondent has met the criteria set forth in ei ther or both 2.a. or 2.b. above. (State when, where, what happened, and who did what to whom) See attached 4. Another no contact order between the individual at risk and the respondent does not exist or the individual at risk does not know or is uncertain as to whether another no contact order exists. does exist. Name of other case: County or State: [I f not Wisconsin ] Type of Case: Case Number: [I f known ] Date of proceeding that resulted in no contact order [I f known ] : Details of no contact order: I REQUEST THE COURT: [M ark any of the following boxes that appl y] 1. I ssue a Temporary Restraining O rder requiring the respondent to a. avoid interference with an investigation of the individual at risk. b. avoid interference with the delivery of protective services to the individual at risk. c. avoid interference wit h a protective placement of the individual at risk. d. avoid interference with the delivery of services to the elder adult at risk. e. cease engaging in or threatening to engage in physical abuse, emotional abuse, sexual abuse, treatment without consent, unreasonable confinement or restraint, financial exploitation, neglect, harassment, stalking of the individual at risk, or mistreatment of an animal. f. avoid the residence of the individual at risk and/or any other location temporarily occupied b y the individual at risk. g. contact the individual at risk. Contact incl public places, in person, by phone, in writing, by electronic communication or device, or in any other manner. h. refrain from removing, hiding, damaging, harming, or mistreating, or disposing of, a household pet. i. allow t he petitioner or a family member or household member of the petitioner acting on his/her behalf to retrieve a household pet. j. Other: [May not be inconsistent with remedies noted above ] 2. S et a time for a hearing on the Petition for an I njunction requiring the respondent to a. avoid interference with an investigation of the individual at risk. b. avoid interference with the delivery of protective services to the individual at risk. c. avoid interference with a protective placement of the individual at risk. d. avoid interference with the delivery of services to the elder adult at risk. e. cease engaging in or threatening to engage in physical abuse, emotional abuse, sexual abuse, treatment without consent, unreasonable confinement or restraint, financial exploitation, neglect, harassment, stalking of the individual at risk, or mistreatment of an animal. f. avoid the residence of the individual at risk or any/or other location temporarily occupied by the individual at risk. g. contact the individual at risk . places, in person, by phone, in wri ting, by electronic communication or device, or in any other manner. h. refrain from removing, hiding, damaging , harming, or mistreating, or disposing of, a household pet. i. allow the petitioner or a family member or household member of the petitioner acting on his/her behalf to retrieve a household pet. j. Other: [May not be inconsistent with remedies noted above ] American LegalNet, Inc. www.FormsWorkFlow.com CV-428, 05/19 Petition for Temporary Restraining Order and/or Petition and Motion for Injunction Hearing (Individual at Risk) 247813.123, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 3 3. If the Temporary Restraining O rder is denied, the person filing the P etition asks the C ourt to schedule an I njunction H earing. 4 . Appoint a guardian ad litem for the individual at risk. (The C ourt shall appoint a guardian ad litem if the petition was filed by a person other than the individual at risk.) 5. Issue an I njunction against the respondent for four years or the following shorter period: . Order t he wireless telephone service provider to transfer to the petitioner each telephone number(s) he/she or a minor child in his/her custody uses. The provider will transfer to the petitioner all financial responsibility for and right to the use of any telephone number(s) transferred. (See form CV - 437, Wireless Telephone Transfer in Injunction Case.) 6. Order the I n junction, which is in effect for not more than 10 years , i f the C ourt finds a substantial risk the respondent may commit 1 st or 2 nd degree intentional homicide, or 1 st , 2 nd or 3 rd degree sexual assault against the petitioner. 7. If the C ourt grants the I njunctio n, the petitioner requests the C ourt a . not order the respondent to surrender his/