Free Notice to Elderly or Disabled Person and Request for Hearing - Oregon

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF LINN ) ) ) ) ) ) ) ) ) CASE NO:__________________________ NOTICE TO ELDERLY PERSON OR PERSON W ITH DISABILITIES / OBJECTIONS AND REQUEST FOR HEARING [Elderly Person s and Pe rsons with Disab ilities Abuse Pre vention Act]

_____________________________________ Petitioner (your na me) Guardian Petitioner,
vs. _____________________________________ Respondent (person to be restrained)

THIS FORM MUST BE ATTACHED TO THE SERVICE COPY OF PETITION AND RESTRAINING ORDER. NOTICE TO __________________________________ (Name of person on whose behalf the "Guardian Petitioner" is petitioning): A T EMPORARY R ESTRAINING O RDER H AS B EEN ISSUED BY THE C OURT AT THE R EQUEST OF (NAME OF GUARDIAN PETITIONER) _________________________________________________ A GAINST (NAME OF RESPONDENT) ________________________. T HIS O RDER IS E FFECTIVE IMMEDIATELY AND R ESTRAINS THE R ESPONDENT FROM THE A CTIONS S PECIFIED IN THE O RDER. IF Y OU O BJECT TO THE C ONTINUATION OF THIS O RDER OR W ISH TO R EQUEST A H EARING, Y OU MUST C OMPLETE THIS F ORM AND M AIL OR D ELIVER IT T O (ADDRESS OF COURT): ______________________________________________________________________________ ______________________________________________________________________________ NOTICE OF RETAINED RIGHTS A LTHOUGH THIS O RDER WAS ISSUED AT THE R EQUEST OF YOUR G UARDIAN OR G UARDIAN A D LITEM, Y OU R ETAIN C ERTAIN R IGHTS INCLUDING THE R IGHT TO: C ONTACT AND R ETAIN C OUNSEL (LAWYER, ATTORNEY, LEGAL REPRESENTATIVE) H AVE A CCESS TO YOUR P ERSONAL R ECORDS F ILE O BJECTIONS TO THE R ESTRAINING O RDER R EQUEST A H EARING P RESENT E VIDENCE AND C ROSS-E XAMINE W ITNESSES AT ANY H EARING (OR HAVE YOUR LAWYER , ATTORNEY OR LEGAL REPRESENTATIVE DO SO) OJBECTIONS and REQUEST FOR HEARING If You Have Objections to the Restraining Order, You May Inform the Court of Them by Filling Out the Information Below and Mailing it to the Court at the Address Above. You may also Request a Hearing. Requests for hearing must be made within 30 days after you receive the order. You must include your address and telephone number with your request for a hearing. The hearing will be held within 21 days. At the hearing, a judge will decide whether the order should be canceled or changed. The only purpose of this
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hearing will be to determine if the terms of the court's order should be canceled, changed, or extended. Keep in mind that this order remains in effect for one year, or until the court that issued the order amends or dismisses it. It may also be renewed upon good cause shown, regardless of whether there has been a further act of abuse. OBJECTIONS I, _____________________________(name), am the elderly person or person with disabilities who is the subject of the attached Restraining Order. I object to the Restraining Order for the following reasons (describe in detail): REQUEST FOR HEARING

I request a hearing to contest all or part of the Order as follows (mark one or more): The Order restraining respondent from contacting or attempting to contact
me. Other (describe parts of the order you object to and want changed):

I -(will) - (will not) be represented by an attorney at the hearing. Notice of the time and place of the hearing can be mailed to me at the address below my signature. (If you completed this document without the assistance of an attorney, you are required to complete truthfully the certificate below.) I certify that: (check the blank that applies) ___ I selected this document for myself, and I completed it without paid assistance and without assistance from an attorney. ___ I paid, or will pay, money to _____________________________________ for assistance in preparing this docum ent. Submitted by: __________________________________________________________________ Print Name Address or Contact Address Petitioner Guardian Petitioner _____________________________________________ Attorney for Petitioner/Guardian Petitioner OSB No: Telephone or Contact:___________________________________________ Telephone Number(s)_____________________________________________

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