Free CIRCUIT COURT OF ILLINOIS - Illinois

DOMESTIC VIOLENCE ORDER OF PROTECTION
INSTRUCTIONS AND FORMS

Note to Internet User: Following are some 30 pages that contain forms and instructions for completing and filing a petition for an Order of Protection. The forms are also available at the Circuit Clerk's office at the Madison County courthouse. The page immediately following this one outlines the criteria for who qualifies for an Order of Protection. Scroll through the document to view all of the forms. For your convenience, you may print copies of these pages and complete them prior to coming to the courthouse.

PEOPLE PROTECTED BY THE ILLINOIS DOMESTIC VIOLENCE ACT
THE ILLINOIS DOMESTIC VIOLENCE ACT SAYS THAT YOU CAN ONLY GET AN ORDER OF PROTECTION IF YOU MEET ONE OF THE FOLLOWING SITUATIONS:

married to the person who hurt you; separated or divorced from the person who hurt you; related to the person who hurt you. . .
(that is, a parent, step-parent, child, aunt, uncle, grandparent, cousin, or someone with whom you have a child -- or someone with whom you say you have a child);

dating (or formerly dated) the person who hurt you; engaged to (or formerly engaged to) the person who hurt you; living with (or formerly lived with) the person who hurt you; an adult with disabilities

NOTICE TO PERSONS SEEKING ORDERS OF PROTECTION
Closing time for Family Court is 4:30 pm Monday through Friday. Processing the paperwork for Orders of Protection usually takes approximately one (1) hour to complete. If an Emergency Order of Protection is granted by the judge, the clerk must process the pleadings, then make copies, and prepare a summons for you to take to the Madison County Sheriff's department for service upon the Respondent. The Respondent must be served by the Sheriff before action can be taken against the Respondent. ALL PETITIONS FOR ORDER OF PROTECTION SHOULD BE COMPLETED AND DELIVERED TO THE CIRCUIT CLERK'S OFFICE PRIOR TO 3:00 P.M. If it is 3:00 pm or later and your situation is such that you need an emergency order of protection today complete the necessary forms as quickly as possible and return them to the Circuit Clerk. If your situation is such that there is no threat of immediate injury or harm to you before you can return to court the next day, you may take the paperwork with you and return it to the Circuit Clerk's office the next day between 8:30 am and 3:00 pm. VALID FOREIGN ORDERS OF PROTECTION WILL BE ENFORCED IN ILLINOIS. If you have a valid Order of Protection from another state, bring this order to the Circuit Clerk's office for filing at no cost. The Circuit Clerk will transmit copies of your order to the Madison County Sheriff's department. ORDERS OF PROTECTION AFTER COURT HOURS. If you need an Emergency Order of Protection between 4:30 pm and 8:30 am Monday through Friday, weekends, or holidays; you may contact the Madison County Sheriff's department at 692-4433. Presiding Judge Family Division

INSTRUCTIONS FOR PREPARING PRO SE PETITION AND PROPOSED ORDER OF PROTECTION

In order to obtain a Domestic Violence Order of Protection, you must come within one of the categories of persons protected by the statute. That is, you must be related to the alleged abuser by blood or marriage, live or have lived with them, have a child by them, or have been involved in a dating relationship with them, or be filing on behalf of a high-risk adult. If you do not fit into one of these categories, you cannot get an Order of Protection and you should pursue criminal charges if appropriate or seek advice from an attorney. Employees of the Circuit Clerk office cannot provide legal advice to you. You must prepare your own Petition and Proposed Order to be submitted to the Judge. You must also prepare a LEADS Sheet. Form Petitions and Orders and LEADS Sheets are available from the Circuit Clerk. You can also call the Oasis Women's Center (618-465-1978) or Land of Lincoln Legal Assistance Foundation (618-462-0029) for information and possible assistance in preparing your Petition. Land of Lincoln may also be able to provide legal representation to you at your hearing on entry of a Plenary (final) Order of Protection if you fall within their income guidelines and are otherwise eligible for their services. If you have filed criminal charges against your abuser, you should go to the Office of the State's Attorney located in the Administration Building for information and possible assistance. Copies of the Petition and Order forms are in this Handbook indicating which parts you are to fill out and what information should be given by you. You should be as specific as possible about the abuse/violence that has occurred, giving dates whenever possible, particularly with respect to the most recent event(s) that led to your filing the Petition. You MUST establish on your papers the reason an Order of Protection should be entered in your case and if you are seeking an Emergency Order without notice to the other party, you must also establish on your papers a proper reason for that Order to be issued. PLEASE PRINT ALL INFORMATION CLEARLY. Mark on your Petition all the remedies that you are requesting. If you are seeking an Emergency Order, mark on your proposed Order only those remedies that can be granted in an Emergency Order. The other remedies, if granted by the Court, can be added at the time of entry of a Plenary (final) Order in your case. When your Petition and proposed Order have been completed by you, take them back to the Circuit Clerk's office along with this Handbook. Your file will then be taken to the Judge who will consider your request for an Emergency Order of Protection. If an Order of Protection is granted and children are covered by it, you instruct the Circuit Clerk to notify the school of the Order of Protection. You will be required to complete the form for notifying the school. If the Judge declines to enter an Emergency Order of Protection without prior Notice to the other party, your case will be set for hearing on a later date. A notice for the hearing will be given to you. A deputy circuit clerk will make the summons and copies of the Petition, including copies for you and for service on the other party, which you will then have to take to the Sheriff's Department yourself so that the Sheriff may serve the other party.

If the Judge enters an Emergency Order in your case, the Circuit Clerk will make the summons and copies of the Petition and Order, including copies for you and for service on the other party, which you will have to then take to the Sheriff's Department yourself so that the Sheriff can serve the other party. If an Emergency Order is entered in your case, it must be set for further hearing within 21 days with Notice to the other party. Please be advised that any order of child or spousal support that may be granted as part of an Order of Protection will terminate when the Order terminates. At the next hearing in your case and after service on the other party, the Court may enter a Plenary (final) Order of Protection to last up to two years. Both parties are entitled to be heard by the Court at that hearing as to whether your Order should be entered or extended. These proceedings are designed to protect victims of domestic violence and abuse. However, if you do not appear for this hearing, your case will be dismissed and any Emergency Order that may have been entered will expire. Any Order for the transfer of personal property to be supervised by the Sheriff or a Police Department is subject to the availability of the Sheriff or Police Department. It is the responsibility of a Petitioner who requests that the transfer of personal property be supervised by an officer to contact the Sheriff or Police Department to make arrangements for an officer to be present for the transfer of property.

If you do not print clearly, YOU MAY BE REQUIRED TO DO THE petition again.

CIRCUIT COURT OF ILLINOIS THIRD JUDICIAL CIRCUIT MADISON COUNTY
Case # Petitioner's Name (Person desiring protection) I am filing on behalf of: myself minor child(ren) dependent high risk adult:
(Full Name) (Age)



Independent Criminal Juvenile Other Civil Proceeding

(file stamp)

v. Respondent's Name (Person you desire protection from)

VERIFIED PETITION FOR ORDER OF PROTECTION
I request an Order of Protection against I am requesting an Emergency Order of Protection. I did not give the Respondent notice that I am seeking protection because I fear that giving notice would result in further abuse or because the abuse is likely to recur before I return to court. Good cause exists for granting the remedy or remedies requested without prior service of process or notice.
(Name of Respondent)

.

PETITIONER INFORMATION
The Petitioner's address for the purpose of service of notice is:
(Street / P.O. Box) (City) (State) (Zip Code)

Check this box, if the above address is an Alternate Address for Service of Notice because disclosure of abused person's actual address would risk further abuse. Persons to be included in the Order of Protection, in addition to the Petitioner, are:
Full Name Age State of Residence

Relationship to Petitioner

RESPONDENT INFORMATION
Date of Birth: ______________ (mm/dd/yyyy) Social Security Number: Weight: Height: ft. Respondent's Current Address:
(Street / P.O. Box) (City) (State) (Zip Code)

Unknown Sex: Male Female Race: Eye color: Hair color:

in.

Respondent's Work Address:
(Street / P.O. Box) (City) (State) (Zip Code)

Distinguishing Features (scars, marks, tattoos, etc.):

RELATIONSHIP CODE
The Petitioner/Abused Person stands in the following relationship to (check all that apply): RELATIONSHIP RELATIONSHIP Spouse (SE) Parent (PA) Ex-Former Spouse (XS) Sibling (Brother/Sister) (SB) Boyfriend/Girlfriend (BG) Step-child (SC) (Dating Relationship) Child in Common (CC) Step-sibling (SS) (parties not married) Shared/common dwelling Step-parent (SP) (CS) Child (CH) Grandchild (GC) the Respondent RELATIONSHIP Grandparent (GP) In-Law (IL) Person with Disability (PD) Person Responsible for High-Risk Adult (PR) Personal Assistant or Caregiver to Person with Disability (PC) Other Related by Blood or Marriage (OF)

BACKGROUND INFORMATION
1. Is there or has there ever been an Order of Protection in any state and county naming you as the Petitioner or Respondent? Yes No If yes, please provide the following information for each Order of Protection: Name of Petitioner Name of Respondent St/County Case Number Date of expiration
(mm/dd/yyyy)

2. Has a child/dependent/high risk adult of either party been designated as either a Respondent or protected person in any other Order of Protection, Custody or Guardianship proceeding? Yes No If yes, please provide the following information for each Order: Name of Petitioner Name of Respondent St/County Case Number Date of expiration
(mm/dd/yyyy)

3. Are there now, or have there ever been, any civil, criminal, or divorce proceedings involving you, one of the protected persons and/or the Respondent? Yes No None Known If yes, please list all pending cases below. a. Type of Case: State/County: b. Type of Case: State/County: c. Type of Case: State/County: Result: Case # (if known) Result: Case # (if known) Result: Case # (if known) Date Date Date

4. Venue is appropriate in this county because: The Petitioner resides here. The Respondent resides here. The abuse occurred here. The Petitioner is here temporarily to avoid abuse.

5. I am requesting an Order of Protection because the Respondent did the following things on the dates and times indicated below. (Be Specific) (Include the relevant history of abuse, the effect the
abuse had on you, and the date and place that each incident occurred. Attach additional pages, if necessary)

Date(s)

Description of Incident(s)

Continued on attached page(s)

REMEDIES SECTION
(750 ILCS 60/214)

PURSUANT TO THE ILLINOIS DOMESTIC VIOLENCE ACT ("THE ACT"), THE PETITIONER SEEKS THE FOLLOWING REMEDIES:

PART A. REMEDIES INVOLVING PERSONAL PROTECTION
1. (R01) With respect to all protected persons, that the Respondent be prohibited from committing the following acts of abuse or threats of abuse (check all that apply): Harassment, interference with personal liberty, physical abuse, or stalking. Intimidation of a dependent. Willful deprivation. Neglect. Exploitation. 2. (R03) That Respondent be ordered to stay away from Petitioner and other protected person(s). a. That the Respondent be ordered to stay person(s). b. That the Respondent is ordered to stay other protected person(s), currently located at ft. away from Petitioner and other protected ft. away from the residence of Petitioner and/or . c. That Respondent be ordered not to communicate in any way ­ directly, indirectly, or through third parties - with Petitioner and/or other protected persons, including, but not limited to phone, written notes, mail, email, or fax. d. That Respondent be prohibited from entering or remaining while Petitioner and/or protected person(s) is/are present at: Their place of residence, currently located at . Their place(s) of employment, located at . Their day care / school(s), located at . Any of the following specified places, when Petitioner and/or protected person(s) is/are present: . 3. (R14) That Respondent be prohibited from entering or remaining in the residence or household while under the influence of drugs or alcohol and constituting a threat to the safety or well-being of Petitioner or Petitioner's children.

PART B. REMEDIES INVOLVING PROPERTY
property (750 ILCS 60/214(b)(2)).

(These remedies do not affect title to

1. (R02) That the Petitioner be granted exclusive possession of, and Respondent be prohibited from entering or remaining present at the residence/household located at:
(Street) (City) (State) (Zip Code)

(Check one) Petitioner has a right to occupancy and Respondent has no such right, or Petitioner and Respondent both have right to occupancy, but the balance of hardships favors Petitioner's occupancy over Respondent's. 2. (R10) That with respect to personal property possession should be awarded as follows: a. Petitioner be granted the following personal property: . b. That the Respondent be ordered to promptly make available to the Petitioner the following property over which the Respondent has possession or control: . (Check as applies) The Petitioner, but not Respondent, owns the property, or The property is jointly owned by the parties, and sharing it would risk abuse or is impracticable and the balance of hardships favors temporary possession by Petitioner, and/or Petitioner claims property as marital property, and a proceeding has been filed under the Illinois Marriage and Dissolution of Marriage Act ("IMDMA"). c. That Respondent be given his/her clothing personal adornments medicine other personal property, namely 3. (R10) That personal property be transferred: at the residence, or at
(Street) (City) (State) (Zip Code)

.

That the transfer of personal property take place in the presence of: law enforcement, or an agreed-upon third party, namely Respondent Petitioner have the right to enter the residence to retrieve the property but only in the presence of law enforcement or the designated third party. Time and date of transfer: 4. (R11) That Respondent be prohibited from taking, transferring, encumbering, concealing, damaging, or otherwise disposing of the following real and/or personal property: . (Check as applies) Petitioner, but not Respondent, owns the property, or The Parties own the property jointly, and the balance of hardships favors granting this remedy, and/or Petitioner claims property as marital property and a proceeding has been filed under the IMDMA. 5. (R11) That Respondent be prohibited from using financial or other resources of an aged member of the family or household for the profit or advantage of Respondent or any other person.

PART C. REMEDIES INVOLVING CHILDREN
List the full name, age, and the state of residence of all children not listed on page 1 of this petition whose custody and or visitation may be affected by the issuance of an order of protection against the respondent. Any prior Orders of Protection, Custody or Guardianship proceedings affecting the child should be listed in the Background Information (page 2 of 11) of this petition.
Full Name Age State of Residence Relationship to Petitioner

1. That the primary caretaker of the minor child(ren) is Petitioner Respondent Other Person:
(Name and Address)

2. (R05) That Petitioner be granted the physical care and possession of the minor child(ren) of the parties, and that: a. Respondent be ordered to return the minor children to the physical care of: Petitioner Other
(Name and Address)

on presence of

at

am/pm in the .

b. Respondent be ordered not to remove the minor child(ren) from the physical care of the Petitioner, school/school grounds, or babysitter/daycare provider. c. Within 24 hours of the issuance of the Order, the Circuit Clerk is directed to send written notice of the Order to any protected child's day care or school, specifically to the following:

(Provide child's name, then Name and Address for each child's school / day care)

3. (R06) That the Court award Petitioner temporary custody of the minor child(ren) of the parties. (Please note, temporary custody is not available as a remedy in an emergency order of
protection).

a. The children were born prior to or during the course of the marriage between the parties; b. The parties are unmarried; the children are children in common of the parties; and there has / has not been a legal determination of parentage. c. If neither of the above applies, please explain here: .

4. (R07) (Visitation) That the Court provide for visitation as follows: a. Deny/ Restrict visitation because the Respondent has or is likely to: Abuse or endanger the minor child(ren) during visitation. Use visitation as an opportunity to abuse or harass Petitioner, Petitioner's family, or household members. Improperly conceal or detain the minor child(ren). Act in a manner that is not in the best interest of the minor child(ren). b. Reserve visitation until further hearing. c. Allow the Respondent to have visitation with the minor child(ren): Every _________________________________ from Each weekend from Every other weekend from Other: Holidays: from am/pm to d. Due to the necessity of protecting Petitioner from further abuse, that Respondent be prohibited from going to Petitioner's residence to meet the minor child(ren) for visitation. e. That the Respondent be ordered to pick up and return the child(ren) for visitation at:
(Street Address / City / State)

am/pm to am/pm to am/pm to

am/pm. am/pm. am/pm. . am/pm.

.

f. That visitation take place at
(Street Address / City / State)

and that transportation be provided by g. That visitation be supervised by who has filed or will file an affidavit accepting responsibility and acknowledging accountability to the Court. h. Further, that the court order the Respondent to return the child(ren) to Petitioner or Petitioner's designated person immediately at the end of visitation. i. That the Respondent be allowed visitation that the Court finds to be in the best interests of the child(ren). 5. (R08) That the Respondent be ordered not to conceal the minor child(ren) within the State or remove the child(ren) from the State of Illinois. 6. (R09) That the Respondent be ordered to appear in Court Alone With the minor children To prevent abuse, neglect, removal or concealment of the child, To return the child to the custody or care of the Petitioner, or To permit a court-ordered interview or examination of the child or Respondent. 7. (R15) That Respondent be denied access to and be prohibited from inspecting, obtaining, or attempting to inspect or obtain school or any other records of the minor child(ren) in the care of the Petitioner because: Petitioner is requesting that the Order of Protection prohibit Respondent from having contact with the minor child(ren), or Petitioner's actual address is omitted due to the risk of further abuse, or It is necessary to prevent abuse or wrongful removal or concealment of the minor child(ren).

.

PART D. FIREARMS (Respondent must be present in court or have had actual notice
of these proceedings before a turnover of firearms can be ordered.) 1. (R14.5) That the Respondent be ordered to turn over any and all firearms in his/her possession to a law enforcement agency because: Respondent has used or threatened to use firearms against me, and/or is likely to use firearms illegally against me. Further, Respondent possesses a firearm. has a history of violence. has a history of possession/use of firearms. carries a firearms on his/her person in a vehicle. (Make and model of vehicle: ) may be a threat to the safety of the public or police officer when encountered. is, or has been known to be, suicidal. 2. The Respondent has the following firearms (describe each):
Description Location

PART E. ECONOMIC REMEDIES (Economic remedies are not available at the
Emergency hearing.) 1.

(R12) That the Court order payment of support. a. Petitioner requests that Respondent be ordered to pay temporary child support. b. Petitioner requests that Respondent be ordered to pay temporary support to the Petitioner. c. Respondent is unemployed employed by:
at and has an approximate take-home pay of $ ___/___ of the month monthly.
(Employer) (Street Address) (City/State)

weekly bi-weekly

2. (R13) That Respondent be ordered to pay Petitioner for losses suffered as a direct result of abuse, neglect, or exploitation, including: Medical expenses $ (if known) Lost earnings Repair/replacement of property damaged or taken Reasonable attorneys' fees $ $ $ (if known) (if known) (if known) (if known) (if known) (if known)

Moving and other travel expenses $ Reasonable expenses for housing other than a domestic violence shelter/meals $ Expenses for search and recovery of children $

Other $ (if known) If you desire payment for any of the above, please bring documentation (receipts, etc.) to the hearing. 3. (R16) That Respondent be ordered to reimburse a shelter providing temporary housing or counseling to Petitioner.

PART F. MISCELLANEOUS REMEDIES
1. (R04) That the Respondent be ordered to undergo and successfully complete counseling. (If you desire that the Respondent undergo counseling, you should check this box, but this remedy is not available at the Emergency hearing.) 2. (R17) That Respondent be further ordered and enjoined as follows:

WHEREFORE, Petitioner moves the Court to grant the relief requested in this petition.

VERIFICATION
Under the penalties of perjury as provided by law pursuant to section 1-109 of the code of civil procedure, the undersigned certifies that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and belief and as to such matters the undersigned certifies as aforesaid that the undersigned verily believes the same to be true.

Signature of Petitioner

Phone number of Petitioner

Attorney for Petitioner: Name: Address: City: Phone: ARDC: State: Fax: Zip Code:

DEFINITION OF TERMS USED IN THIS PETITION
1. Abuse: "Abuse" means physical abuse, harassment, intimidation of a dependent, interference with personal liberty or willful deprivation but does not include reasonable direction of a minor child by a parent or person in loco parentis. 2. Domestic Violence: Domestic Violence means abuse as defined in paragraph one. 3. Exploitation: "Exploitation" means the illegal, including tortuous, use of a high-risk adult with disabilities or of the assets or resources of a high-risk adult with disabilities. Exploitation includes, but is not limited to, the misappropriation of assets or resources of a high-risk adult with disabilities by undue influence, by breach of a fiduciary relationship, by fraud, deception, or extortion, or the use of such assets or resources in a manner contrary to law. 4. Family or Household Members: Include spouses, former spouses, parents, children, stepchildren and other persons related by blood or by present or prior marriage, persons who share or formerly shared a common dwelling, persons who have or allegedly have a child in common, persons who share or allegedly share a blood relationship through a child, persons who have or have had a dating or engagement relationship, and persons with disabilities and their personal assistants. For purposes of this paragraph, neither a casual acquaintanceship nor ordinary fraternization between two individuals in business or social contexts shall be deemed to constitute a dating relationship. In the case of a high-risk adult with disabilities, "family or household members" includes any person who has the responsibility for a high-risk adult as a result of a family relationship or who has assumed responsibility for all or a portion of the care of a high-risk adult with disabilities voluntarily, or by express or implied contract, or by court order. 5. Harassment: "Harassment" means knowing conduct which is not necessary to accomplish a purpose that is reasonable under the circumstances, would cause a reasonable person emotional distress, and does cause emotional distress to the petitioner. Unless the presumption is rebutted by a preponderance of the evidence, the following types of conduct shall be presumed to cause emotional distress: a) creating a disturbance at petitioner's place of employment or school; b) repeatedly telephoning petitioner's place of employment, home or residence; c) repeatedly following petitioner about in a public place or places; d) repeatedly keeping petitioner under surveillance by remaining present outside his or her home, school, place of employment, vehicle or other place occupied by petitioner or by peering in petitioner's windows; e) repeatedly threatening to improperly remove a child of petitioner's from the jurisdiction, improperly concealing that child from petitioner or making a single such threat following an actual or attempted improper removal or concealment; f) improperly concealing a minor child from petitioner, repeatedly threatening to improperly remove a minor child of petitioner from the jurisdiction or from the physical care of petitioner, repeatedly threatening to conceal a minor child from petitioner, or making a single such threat following an actual or attempted improper removal or concealment, unless respondent was fleeing an incident or pattern of domestic violence; or g) threatening physical force, confinement or restraint on one or more occasions.

6. Interference with Personal Liberty: "Interference with personal liberty" means committing or threatening physical abuse, harassment, intimidation or willful deprivation so as to compel another to engage in conduct from which she or he has a right to abstain or to refrain from conduct in which she or he has a right to engage. 7. Intimidation of a Dependent: "Intimidation" means subjecting a person who is dependent because of age, health or disability to participation in, or the witnessing of: physical force against another or physical confinement or restraint of another which constitutes physical abuse as herein defined, regardless of whether the abused person is a family or household member. 8. Neglect: "Neglect" means the failure to exercise that degree of care toward a high-risk adult with disabilities which a reasonable person would exercise under the circumstances and includes but is not limited to: a) the failure to take reasonable steps to protect a high-risk adult with disabilities from acts of abuse; b) the repeated, careless imposition of unreasonable confinement; c) the failure to provide food, shelter, clothing, and personal hygiene to a high-risk adult with disabilities who requires such assistance; d) the failure to provide medical and rehabilitative care for the physical and mental health needs of a high-risk adult with disabilities; or e) the failure to protect a high-risk adult with disabilities from health and safety hazards. 9. Physical Abuse: "Physical abuse" includes sexual abuse and means any of the following: a) knowing or reckless use of physical force, confinement, or restraint; or b) knowing, repeated and unnecessary sleep deprivation; or c) knowing or reckless conduct which creates an immediate risk of physical harm. 10.Stalking: "Stalking" means knowingly and without lawful justification, on at least two (2) separate occasions, following another person or placing the person under surveillance or any combination thereof and: a) at any time transmitting a threat of immediate or future bodily harm, sexual assault, confinement or restraint and the threat is directed towards that person or a family member of that person; or b) placing that person in reasonable apprehension of immediate or future bodily harm, sexual assault, confinement or restraint; or c) placing that person in reasonable apprehension that a family member will receive immediate or future bodily harm, sexual assault, confinement, or restraint. 11.Willful Deprivation: "Willful deprivation" means willfully denying a person who because of age, health or disability requires medication, medical care, shelter, food, therapeutic device, or other physical assistance, and thereby exposing that person to the risk of physical, mental or emotional harm, except with regard to medical care or treatment when the dependent person has expressed an intent to forego such medical care or treatment. This paragraph does not create any new affirmative duty to provide support to dependent persons.

Court Ph.

618 692-6250 THIRD MADISON
JUDICIAL CIRCUIT State of ILLINOIS

Emergency Order of Protection
Case No. PETITIONER

Court County

First

Middle

Last
(file stamp)

Petitioner's Address/ Alternative Address:

And/or on behalf of other protected person(s) Child(ren) as noted on page 6, Part C of this order Other

RESPONDENT

RESPONDENT IDENTIFIERS
SEX RACE DOB HT. WT.

First

Middle

Last

Relationship to Petitioner: ___________________ Respondent's Address:

EYES

HAIR

SOCIAL SECURITY #

_________________________________________ DRIVER'S LIC. # (Home) _________________________________________ (Work)

STATE

EXPIR. DATE

Caution indicators:

Distinguishing Features (scars, marks, tattoos, martial arts):

(A) Considered armed and /or dangerous (S) Suicidal (Y) Considered armed, dangerous and suicidal
THE COURT FINDS: That it has jurisdiction over the Petitioner and subject matter and the Respondent will be provided with reasonable notice and an opportunity to be heard within the time required by Illinois law. THE COURT ORDERS: (Additional terms are set forth herein) That Respondent is prohibited from committing further acts of abuse or threats of abuse. (See R01) That Respondent is ordered to stay away from Petitioner and/or other protected persons. (See R03) The Circuit Clerk is directed to send within 24 hours: Daycare / School Notice(s) (See page 6). Firearms Notice(s) (See page 8). The terms of this Order shall be effective until Date/Time: t

Hearing on entry of Plenary/Interim Order of Protection:

at (Date) (Time) at the Madison County Courthouse, 155 N. Main Street, Edwardsville, Illinois in Courtroom: TBA. A PLENARY (FINAL) ORDER OF PROTECTION MAY BE ENTERED AGAINST YOU BY DEFAULT IF YOU FAIL TO APPEAR AT SUCH HEARING.

NOTICES CONCERNING THIS

EMERGENCY ORDER OF PROTECTION
WARNING TO RESPONDENT
Violating this Order of Protection is punishable by imprisonment or fine or both, and can cause your bond to be revoked, result in a contempt of court citation against you, or the filing of a criminal charge. This protection order is enforceable, even without registration, in all 50 states, the District of Columbia, tribal lands, and the U.S. Territories pursuant to the Violence Against Women Act (18 U.S.C. § 2265). Violating this order of protection may subject you to federal charges and punishment. 18 U.S.C. §§ 2261-2262. Only the court can change this order. The Petitioner cannot give you legal permission to change this order. If you go near the Petitioner, even with the Petitioner's consent, you may be arrested. Unless the court modifies/dismisses this order, you can be arrested for violating this Emergency Order of Protection. You act at your own risk if you disregard this WARNING. You have been served with notice that the Petitioner has filed for a Plenary or Interim Order of Protection (effective for up to two years), and have been provided with a date on which you must appear in court if you wish to contest entry of the order. If you fail to appear, an Order of Protection may be issued in your absence.

NOTICE TO PETITIONER

You cannot change the terms of this order by your words or actions. If the Court has ordered no contact or exclusive possession of the residence, only the Court can allow the Respondent to contact you or return to the residence. If you and the Respondent want to resume your relationship, you must ask the Court to modify or dismiss this Order of Protection.

If you wish to ask the court for an Interim or Plenary (Final) Order of Protection (effective for up to two years), you must appear in court on the date set for a hearing.

NOTICE TO ALL LAW ENFORCEMENT AGENCIES AND OFFICERS
This Order of Protection is enforceable, even without registration, in all 50 states, the District of Columbia, tribal lands, and the U.S. Territories pursuant to the Violence Against Women Act (18 U.S.C. § 2265). Violating this Order of Protection may subject the Respondent to state and/or Federal charges and punishment (18 U.S.C. §§2261-2262). The Respondent may be subject to Federal criminal penalties for possessing, transporting, shipping, or receiving any firearm or ammunition under the Gun Control Act (18 U.S.C. §922(g)(8) and (9).

NOTICE TO RESPONDENT Any knowing violation of an order of protection forbidding physical abuse, neglect, exploitation, harassment, intimidation, interference with personal liberty, willful deprivation, or entering or remaining present at specified places when a protected person is present, or granting exclusive possession of the residence or household or granting a stay away order is a Class A misdemeanor and a second or subsequent violation is a Class 4 felony. The granting of exclusive possession of the residence or household shall constitute notice forbidding trespass to land. Any knowing violation of an order awarding legal custody or physical care of a child or prohibiting removal or concealment of a child may be a Class 4 felony. Stalking is a Class 4 felony for a first offense and a Class 3 felony for a subsequent offense. Any willful violation of any order is contempt of court. Any violation may result in fine or imprisonment.

FINDINGS [Jurisdiction]
The Court, having reviewed the verified petition and having examined the petitioner under oath or affirmation, finds that:

1. Good cause exists for granting the remedy or remedies requested without prior service of process or
notice because:

A. The harm that Remedies 1, 3, 5, 8, 9, 11, 14, 15, and 17 are intended to prevent would be
likely to occur if the Respondent were given prior notice, or greater notice than was actually given, of the Petitioner's efforts to obtain judicial relief.

B. For Remedy 2, the immediate danger of further abuse of Petitioner by Respondent, if Petitioner
chooses or had chosen to remain in the residence or household while Respondent was given any prior notice or greater notice than was actually given or of Petitioner's efforts to obtain judicial relief, outweighs the hardships to Respondent of an Emergency Order granting Petitioner exclusive possession of the residence or household.

C. For Remedy 10, improper disposition of the personal property would likely occur if the
Respondent were given any prior notice, or greater notice than was actually given, of the Petitioner's efforts to obtain judicial relief, or Petitioner has an immediate and pressing need for the possession of that property (750 ILCS 60/217(a)(3)(iii)).

2. Petitioner's actual address is set forth on page one (1).
or Disclosure of Petitioner's address would risk further abuse. The address set forth below is the address for the purpose of service of notice on the petitioner in this case.
(Street / P.O. Box) (City) (State) (Zip Code)

3. The persons protected by this order are:
Petitioner Minor child(ren) who are so identified on page 6 of 11, Part C of this order. Other protected parties listed in page 1 of 11 of this order.

4. The court has jurisdiction over the minor child(ren) and/or other protected persons.
(750 ILCS 60/208)

RELATIONSHIP CODE: The Petitioner/Abused Person stands in relationship to the Respondent as
(check all that apply): RELATIONSHIP Spouse (SE) Ex-Former Spouse (XS) Boyfriend/Girlfriend (BG) (Dating Relationship) Child in Common (CC) (parties not married) Shared/common dwelling (CS) Child (CH) RELATIONSHIP Parent (PA) Sibling (Brother/Sister) (SB) Step-child (SC) Step-sibling (SS) Step-parent (SP) Grandchild (GC) RELATIONSHIP Grandparent (GP) In-Law (IL) Person with Disability (PD) Person Responsible for High-Risk Adult (PR) Personal Assistant or Caregiver to Person with Disability (PC) Other Related by Blood or Marriage (OF)

FINDINGS [General]
The Court, having reviewed the verified petition and having examined the petitioner under oath or affirmation, finds that: Venue is proper (750 ILCS 60/209). The Respondent has abused the Petitioner and/or the child(ren) so identified on Part C (page 6 of 11) of this order and/or the protected person(s) listed on Page 1 of 11 of this order (750 ILCS 60/214(a)). The abused person(s) is/are unable to bring this Petition on his/her own behalf due to age, health, disability, or inaccessibility (750 ILCS 60/214(a)). The Petition has been filed on behalf of a high-risk adult with disabilities who has been abused, neglected, or exploited by a family or household member. An Order of Protection has previously been entered in the instant proceeding or in another proceeding in which any party, or a child of any party, or both, has/have been designated as either a respondent or a protected person (750 ILCS 60/223.1).

IT IS ORDERED the following remedies that are checked apply in this case.
PART A. REMEDIES INVOLVING PERSONAL PROTECTION 1. (R01)(Police Enforced) With respect to all protected persons, Respondent is prohibited from committing the following acts of abuse or threats of abuse (check all that apply): Harassment, interference with personal liberty, physical abuse, or stalking. Intimidation of a dependent. Willful deprivation. Neglect. Exploitation.

Page 4 of 11 ­ Emergency Order of Protection



2. (R03)(Police Enforced) Stay Away
a. Respondent is ordered to stay _____ ft. away from Petitioner and/or other protected person(s). b. Respondent is ordered to stay _____ ft. away from the residence of Petitioner and/or other protected person(s), currently located at "Stay Away" means for the respondent to refrain from both physical presence and nonphysical contact with the petitioner whether direct, indirect (including, but not limited to, telephone calls, mail, email, faxes, and written notes), or through third parties who may or may not know about the order of protection. c. Respondent is prohibited from entering or remaining while Petitioner and/or protected person(s) is/are present at: Their place of employment at Their school, located at Any of the following specified places, when Petitioner and/or protected person(s) is/are present: . . .

.
3. (R14)(Police Enforced) Respondent is prohibited from entering or remaining in the residence

or household while under the influence of drugs or alcohol and constituting a threat to the safety or well-being of Petitioner or Petitioner's children.
PART B. REMEDIES INVOLVING PROPERTY

1. (R02)(Police Enforced) Petitioner is granted exclusive possession of, and Respondent is prohibited from entering or remaining present at the residence/household located at:
(Street / P.O. Box) (City) (State) (Zip Code)

Petitioner has a right to occupancy and Respondent has no such right, or Petitioner and Respondent both have right to occupancy but the balance of hardships favors temporary possession by Petitioner, the court having considered the factors set forth in 750 ILCS 60/214(c)(2). 2. (R10)(Court Enforced) Personal Property a. Petitioner is granted possession of the following personal property:

b. If the Respondent has possession of the property listed in 2a above, the Respondent shall promptly make it available to the petitioner. With respect to 2a and 2b above, the Court finds as follows: The Petitioner, but not Respondent, owns the property, or The parties own the property jointly, and sharing it would risk abuse or is impracticable and the balance of hardships favors temporary possession by Petitioner, and/or

Petitioner claims property as marital property, and a proceeding has been filed under the Illinois Marriage and Dissolution of Marriage Act ("IMDMA").
c. Respondent is given his/her clothing personal adornments medicine other personal property, namely .

3. (R10)(Police Enforced) Personal property shall be transferred at the residence, or at
(Street) (City) (State) (Zip Code)

That the transfer of personal property shall take place in the presence of: law enforcement, or an agreed-upon third party, namely Respondent Petitioner shall have the right to enter the residence to retrieve the property but only in the presence of law enforcement or the designated third party. Time and date of transfer: (This transfer does not affect title to property (750 ILCS 60/214(b)(2)). 4. (R11)(Court Enforced) Respondent is prohibited from taking, transferring, concealing, encumbering, damaging, or otherwise disposing of the following real or personal property: , except as explicitly authorized by the Court because: Petitioner, but not Respondent, owns the property, or The parties own the property jointly, and the balance of hardships favors granting this remedy, and/or Petitioner claims the property as marital property and a proceeding has been filed under the IMDMA. 5. (R11)(Court Enforced) Respondent is prohibited from using financial or other resources of an aged member of the family or household for the profit or advantage of Respondent or any other person. PART C. REMEDIES INVOLVING CHILDREN The minor child(ren) of the parties is/are:
Full Name Age State of Residence Relationship to Petitioner Included as Protected Party

1. The primary caretaker of the minor child(ren) is Petitioner Respondent Other person:
(Name and Address)

.

2. (R05)(Police Enforced) Petitioner is granted the physical care and possession of the minor child(ren) of the parties, and a. Respondent is ordered to return the minor children to the physical care of: Petitioner Other
(Name and Address)

on of

at

am/pm in the presence .

b. Respondent is further ordered not to remove the minor child(ren) from the physical care of the Petitioner, school/school grounds, or babysitter/daycare provider, or other person in loco parentis (750 ILCS 60/214(b)(5)).

c. The Circuit Clerk shall, within 24 hours of the issuance of this Order, send written notice of the Order to any protected child's day care or school to the following: (list child's name and the name and address of each child's school/day care.

If this box is checked, the petitioner shall provide this information to the clerk by a separate written notice which the clerk shall impound to prevent further abuse 3. (R07)(Court Enforced) Visitation of the minor child(ren) a. Visitation is denied / restricted because Respondent has or is likely to: Abuse or endanger the minor child(ren) during visitation. Use visitation as an opportunity to abuse or harass Petitioner, Petitioner's family, or household members. Improperly conceal or detain the minor child(ren). Act in a manner that is not in the best interest of the minor child(ren). b. Visitation is reserved until further order of court, or until c. Visitation is granted as follows: (Check all that apply) Every Each weekend or Alternating weekends. Friday at __________ am/pm to Saturday at __________ am/pm Friday at __________ am/pm to Sunday at _________ am/pm Saturday at ________ am/pm to Sunday at __________ am/pm Saturday at ________ am/pm to Saturday at ________ am/pm Sunday at _________ am/pm to Sunday at ________ am/pm from am/pm to

.

. am/pm.

Major holidays shall be divided as follows: . d. The Court, finding it necessary to protect Petitioner or other protected parties from further abuse, prohibits Respondent from going to Petitioner's residence to meet the minor child(ren) for visitation. e. Visitation Transportation Each parent shall provide transportation one-way for visitation, or shall provide all transportation for visitation, or .
(Street Address/City)

Other arrangements f. Visitation shall take place at

g. Visitation is to be supervised by who is approved to supervise visitation and who has filed an affidavit accepting responsibility and acknowledging accountability to the Court. h. Respondent shall return the child(ren) to Petitioner or Petitioner's designated person immediately at the end of visitation.

Notice to Respondent
The Petitioner may, by law, deny Respondent access to the minor child(ren) if, when Respondent arrives for visitation, Respondent is under the influence of drugs or alcohol and constitutes a threat to the safety and well-being of Petitioner or Petitioner's minor child(ren) or is behaving in a violent or abusive manner (750 ILCS 60/214(b)(7)).

4. (R08)(Police Enforced) Respondent is ordered not to conceal the minor child(ren) within the State or remove the child(ren) from the State of Illinois. 5. (R09)(Court Enforced) Respondent is ordered to appear at the in Courtroom _____, on 20___ at am/pm Alone / With the minor children: To prevent abuse, neglect, removal or concealment of the child, To return the child to the custody or care of the Petitioner, or To permit a court-ordered interview or examination of the child or Respondent. 6. (R15)(Court Enforced) Respondent is denied access to and is prohibited from inspecting, obtaining, or attempting to inspect or obtain school or any other records of the minor child(ren) in the care of the Petitioner because: The Order of Protection prohibits Respondent from having contact with the minor child(ren), or Petitioner's actual address is omitted due to the risk of further abuse, or It is necessary to prevent abuse or wrongful removal or concealment of the minor child(ren). PART D. MISCELLANEOUS REMEDIES (R17) Respondent is further ordered and enjoined as follows: , ,

PART E. RULINGS PURSUANT TO 750 ILCS 60/221 (a)(2) and (b)(2)

THIS PAGE TO BE COMPLETED BY JUDGE:
The relief requested in paragraph(s) of the Petition is/are Denied Reserved because the balance of hardships does not support the granting of the remedy, and the granting of the remedy will result in hardship to Respondent that would substantially outweigh the hardship to the Petitioner from the denial of the remedy, or because

THIS EMERGENCY ORDER WAS ISSUED ON:

Date: Time JUDGE am/pm.

I hereby certify that this is a true and correct copy of the original order on file with the court. Clerk of the Circuit Court of (Seal of the Clerk of Circuit Court) Date: County, Illinois

NOTICE TO RESPONDENT: You may petition the court, in accordance with Section 224 of the Act, to reopen the order if you did not receive actual prior notice of the hearing in accordance with Section 211 of the Act, alleging that you have a meritorious defense to the order or that the order, or any of its remedies, was not authorized by the act.

cc: Petitioner Respondent(via Sheriff) Counsel of Record Sheriff Advocate Jail States Attorney

DEFINITION OF TERMS USED IN THIS ORDER
These definitions are incorporated in and made a part of the order to which they are attached.

Abuse: "Abuse" means physical abuse, harassment, intimidation of a dependent, interference with personal liberty or willful deprivation but does not include reasonable direction of a minor child by a parent or person in loco parentis. Domestic Violence: Domestic Violence means abuse as defined in paragraph one. Exploitation: "Exploitation" means the illegal, including tortuous, use of a high-risk adult with disabilities or of the assets or resources of a high-risk adult with disabilities. Exploitation includes, but is not limited to, the misappropriation of assets or resources of a high-risk adult with disabilities by undue influence, by breach of a fiduciary relationship, by fraud, deception, or extortion, or the use of such assets or resources in a manner contrary to law. Family or Household Members: Include spouses, former spouses, parents, children, stepchildren and other persons related by blood or by present or prior marriage, persons who share or formerly shared a common dwelling, persons who have or allegedly have a child in common, persons who share or allegedly share a blood relationship through a child, persons who have or have had a dating or engagement relationship, and persons with disabilities and their personal assistants. For purposes of this paragraph, neither a casual acquaintanceship nor ordinary fraternization between two individuals in business or social contexts shall be deemed to constitute a dating relationship. In the case of a high-risk adult with disabilities, "family or household members" includes any person who has the responsibility for a high-risk adult as a result of a family relationship or who has assumed responsibility for all or a portion of the care of a high-risk adult with disabilities voluntarily, or by express or implied contract, or by court order. Harassment: "Harassment" means knowing conduct which is not necessary to accomplish a purpose that is reasonable under the circumstances, would cause a reasonable person emotional distress, and does cause emotional distress to the petitioner. Unless the presumption is rebutted by a preponderance of the evidence, the following types of conduct shall be presumed to cause emotional distress: a) creating a disturbance at petitioner's place of employment or school; b) repeatedly telephoning petitioner's place of employment, home or residence; c) repeatedly following petitioner about in a public place or places; d) repeatedly keeping petitioner under surveillance by remaining present outside his or her home, school, place of employment, vehicle or other place occupied by petitioner or by peering in petitioner's windows; e) repeatedly threatening to improperly remove a child of petitioner's from the jurisdiction, improperly concealing that child from petitioner or making a single such threat following an actual or attempted improper removal or concealment; f) improperly concealing a minor child from petitioner, repeatedly threatening to improperly remove a minor child of petitioner from the jurisdiction or from the physical care of petitioner, repeatedly threatening to conceal a minor child from petitioner, or making a single such threat following an actual or attempted improper removal or concealment, unless respondent was fleeing an incident or pattern of domestic violence; or g) threatening physical force, confinement or restraint on one or more occasions. Interference with Personal Liberty: "Interference with personal liberty" means committing or threatening physical abuse, harassment, intimidation or willful deprivation so as to compel another to

engage in conduct from which she or he has a right to abstain or to refrain from conduct in which she or he has a right to engage. Intimidation of a Dependent: "Intimidation" means subjecting a person who is dependent because of age, health or disability to participation in, or the witnessing of: physical force against another or physical confinement or restraint of another which constitutes physical abuse as herein defined, regardless of whether the abused person is a family or household member. Neglect: "Neglect" means the failure to exercise that degree of care toward a high-risk adult with disabilities which a reasonable person would exercise under the circumstances and includes but is not limited to: a) the failure to take reasonable steps to protect a high-risk adult with disabilities from acts of abuse; b) the repeated, careless imposition of unreasonable confinement; c) the failure to provide food, shelter, clothing, and personal hygiene to a high-risk adult with disabilities who requires such assistance; d) the failure to provide medical and rehabilitative care for the physical and mental health needs of a high-risk adult with disabilities; or e) the failure to protect a high-risk adult with disabilities from health and safety hazards. Physical Abuse: "Physical abuse" includes sexual abuse and means any of the following: a) knowing or reckless use of physical force, confinement, or restraint; or b) knowing, repeated and unnecessary sleep deprivation; or c) knowing or reckless conduct which creates an immediate risk of physical harm. Stalking: "Stalking" means knowingly and without lawful justification, on at least two (2) separate occasions, following another person or placing the person under surveillance or any combination thereof and: d) at any time transmitting a threat of immediate or future bodily harm, sexual assault, confinement or restraint and the threat is directed towards that person or a family member of that person; or e) placing that person in reasonable apprehension of immediate or future bodily harm, sexual assault, confinement or restraint; or f) placing that person in reasonable apprehension that a family member will receive immediate or future bodily harm, sexual assault, confinement, or restraint. Willful Deprivation: "Willful deprivation" means willfully denying a person who because of age, health or disability requires medication, medical care, shelter, food, therapeutic device, or other physical assistance, and thereby exposing that person to the risk of physical, mental or emotional harm, except with regard to medical care or treatment when the dependent person has expressed an intent to forego such medical care or treatment. This paragraph does not create any new affirmative duty to provide support to dependent persons.

LEADS ENTRY GUIDE LAW ENFORCEMENT SERVICE DATA SHEET
Case Number: ____________________ Respondent Issued: ________________ Expires: _______________

Name: ___________________________________ DOB: ____________ Sex: ___________ Race: ______ HGT: ______ WGT: ______ Hair: _________Beard: ________ Eyes: _______ Moustache: ______ Identifying Marks: ___________________________________________ Address: ______________________________________ Telephone: __________________

Location: ____________________________________________________________________ Employer: _____________________________________ Telephone: __________________

Working Hours: _______________Other Locations: _________________________________ Respondent's Car: Make: ________ Model: _________ Year: ______Color: ________________ Registration: _________________________________________________________________ Remedies
R01 R14 R02 R03 R04 R16 R05 R06 R07 R08 R09 R10 R11 R12 R13

R14.5 R15

R17 Describe:_____________________________________________

Petitioner/Protected Address

Name: ________________________________________ DOB: ______________________ Address(es): __________________________________ Phone:
Last, First, MI Relationship Code

Protected Persons
(To include Petitioner's name and relationship to Respondent)

Name #1: _______________________________________ Name #2: _______________________________________ Name #3: _______________________________________ Name #4: _______________________________________ Name #5: _______________________________________ Name #6: _______________________________________ Name #7: _______________________________________ Name #8: _______________________________________

____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________

Miscellaneous
Include BHV Code (Armed, Suicidal or Both)

___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
Entry Date: _____/ _____/ _____ OPR: _______

LEADS #: _______________ Entry Time: _____: _____

Modifications:
Relationship Codes: Child in Common (not married) Grandparent Personal Assit. or Caregiver To Person w/Disability Spouse Ex-Former Spouse

Entry Time: _____:_____

Entry Date: _____/ _____/ _____
BG CS IL PD PR SP OF Child Grandchild Parent Step-child Sibling (Brother/Sister) Step-Sibling

OPR: ______
CH GC PA SC SB SS

CC GP PC SE XS

Boyfriend/Girlfriend (Dating) Shared/common Dwelling In-Law Person w/Disability Person Resp. for High-Risk Adult Step-parent Other Related by Blood/Marriage

MADISON COUNTY SHERIFF'S OFFICE 405 Randle Street Edwardsville, IL 62025

To Whom It May Concern: The Madison County Sheriff's Department must have as much of the information requested below as possible. Respondent's Name: Respondent's Address:
(Note: the Sheriff's Office cannot serve a post office box number)

1. 2. 3.

Respondent's Physical Description:

4.

Directions to address if a rural route box number:

5.

Respondent's Employer's name and address:

6.

Respondent is at work during the hours of:

7.

Other possible location(s) for service on Respondent:

8.

Any special instructions for service:

9.

Respondent's Phone Number(s):

10. Petitioner's Phone Number(s):
(Note: we must have a contact number to give you notification that the order was served.)

11. Date of Hearing:

Your cooperation in this matter is greatly appreciated. Sincerely, Robert J. Hertz Sheriff of Madison County Revised: 09/18/2008

IN THE CIRCUIT COURT THIRD JUDICIAL CIRCUIT MADISON COUNTY, ILLINOIS ) ______________________________, ) Petitioner, ) vs. ) ) ______________________________, ) Respondent. )

Case No. ________________

NOTICE TO SCHOOL OF ORDER OF PROTECTION

Please be advised that the Third Judicial Circuit Court has entered the attached Order of Protection. At the request of the Petitioner whose children attend your day care facility, pre-school, pre-kindergarten, private or public school or college or university, you are receiving this Notice and the attached certified copy of that Order. A copy of this Notice has also been sent to the parties in this case. The Order of Protection expires on the date indicated on its first page. However, the Order of Protection may be extended to a later date or a Plenary (long-term) Order of Protection may be entered at a later date. It is the obligation of the Petitioner to provide subsequent Orders to you that may extend or terminate the Order of Protection. However, if you have a question as to whether an Order of Protection is still in effect, you can call the Clerk's office, Family Division at (618) 692-6250. Matt Melucci, Clerk of the Circuit Court By: Deputy Clerk

I hereby request that the Clerk of the Court notify the day care facility, pre-school, pre-kindergarten, private school, principal office of the public school district, or college or university attended by my child(ren) that an Order of Protection has been entered by the Court. I understand that it is my obligation to provide copies of any subsequent Order that may extend or terminate the Order of Protection.

The name(s) of the child(ren) and the name and address of the place(s) where the Order is to be sent are as follows: Name of Child: ________________________ Date of Birth: ________________________ ________________________
Day care, pre-school, pre-kindergarten, private school or principal office of public school district, college or university

__________________ __________________ __________________

Day care, pre-school, pre-kindergarten, private school or principal office of public school district, college or university

street address

street address

city, state, zip code Petitioner's Name

city, state, zip code Petitioner's Name