COUNTY STATE OF WISCONSIN, CIRCUIT COURT, For Official Use INJUNCTION – Child Abuse (30711) (Order of Protection) Case No. PETITIONER/CHILD First Middle Last Date of Birth of Petitioner/Child Name of Child (if different than Petitioner) Date of Birth of Child (if different than Petitioner) -VS.- RESPONDENT/DEFENDANT SEX RACE First Middle EYE COLOR Please specify Child’s relationship(s) to Respondent/Defendant: adoptive parent cousin spouse grandparent sibling former spouse child (biological/adoptive/step) parent person in dating relationship step parent current or former live-in relationship Other: (be specific) (Check all that apply) HT WT Last Respondent’s/Defendant’s Street Address, City, State, Zip CAUTION: DOB HAIR COLOR Respondent’s/Defendant’s Distinguishing Features (such as scars, marks or tattoos) None known. Respondent/Defendant has access to weapon(s) Type of weapon(s): Location of weapon(s): Weapon(s) were involved in an incident (past or present) with the child. THE COURT FINDS: Findings are on the following page(s) of this injunction. THE COURT ORDERS: Orders are on the following page(s) of this injunction. THIS INJUNCTION SHALL BE EFFECTIVE UNTIL Not to exceed 2 years or until the child victim is 18 years of age, whichever occurs first. NOTIFICATIONS/WARNINGS TO RESPONDENT/DEFENDANT: This order shall be enforced, even without registration, and is entitled to full faith and credit in every civil or criminal court of any state, the District of Columbia, any U.S. Territory, and may be enforced by Tribal Lands (18 U.S.C. Section 2265; Wis. Stats. 813.128). Crossing state, territorial, or tribal boundaries to violate this order may result in federal imprisonment (18 U.S.C. Section 2262). Federal law provides penalties for, and you may be prohibited from possessing, transporting, shipping, receiving or purchasing a firearm, including, but not limited to, a rifle, shotgun, pistol, revolver, or ammunition, pursuant to 18 U.S.C. 922(g)(8). Additional notifications/warnings are on the following page of this injunction. Violation of this order shall result in immediate arrest and is punishable by imprisonment not to exceed 9 months or a fine not to exceed $1,000, or both, and payment of filing and service fees. Only the court can change this order. JC-1692, 01/08 Injunction (Order of Protection – Child Abuse) §813.122, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Injunction (Order of Protection – Child Abuse) Page 2 of 2 Case No.: THE COURT FINDS: 1. The petitioner/child has filed a petition alleging child abuse. 2. Based on the hearing held on the petition, there are reasonable grounds to believe that the respondent/defendant has engaged in, or based upon prior conduct of the child and the respondent/defendant may engage in, abuse of the child. 3. This court has personal and subject matter jurisdiction. The petitioner/child has served upon the respondent/defendant a copy of the petition and notice of the time for a hearing on the issuance of the injunction; or the respondent/defendant has served upon the petitioner/child notice of the time for a hearing on the issuance of the injunction. The respondent/defendant has been properly served and had an opportunity to be heard. . , whose birth date is 4. The child is THE COURT ORDERS: 1. The respondent/defendant avoid the child's residence and/or any premises temporarily occupied by the child now and in the future. 2. The respondent/defendant avoid contacting or causing any person other than a party's attorney to contact the child unless petitioner/child consents in writing and the court agrees the contact is in the best interest of the child. Contact includes: contact at petitioner/child’s home, work, school, public places, in person, by phone, in writing, by electronic communication or device, or by any other means. Contact also means knowingly touching, meeting, communicating or being in visual or audio contact with the child. 3. If requested, the sheriff shall serve and assist in executing this injunction. 4. Other: THE COURT FURTHER ORDERS the respondent/defendant is prohibited from possessing a firearm until the expiration of this injunction. Possession of a firearm is a Class G Felony punishable by a fine not to exceed $25,000 or imprisonment not to exceed 10 years, or both. A respondent/defendant may retain a firearm only if the respondent/defendant is a peace officer and only to the extent required by the peace officer's employer. The respondent/defendant shall immediately surrender any firearm(s) that he or she owns or has in his or her possession to: the sheriff of this county. . the sheriff of the county in which the respondent/defendant resides: . another person: Name and Address DISTRIBUTION: 1. Original - Court 2. Petitioner/Child 3. Respondent/Defendant 4. Law Enforcement The respondent/defendant was present in court and personally served with a copy of this order. BY THE COURT: Circuit Court Judge Name Printed or Typed Date JC-1692, 01/08 Injunction (Order of Protection – Child Abuse) §813.122, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com