Free Petition for Restraining Order for an Elderly Person - Oregon

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF LINN

_____________________________________
Petitioner (your nam e) By and thro ugh : Gua rdian Petitioner:
________________________________________ vs. ________________________________________ Respondent (person to be restrained)

) ) ) ) ) ) ) ) )

CASE NO :__________________________ PETITION FOR RESTRAINING ORDER TO PREVENT ABUSE OF ELDERLY OR DISABLED PERSON [Elderly Persons and Person s with Disabilities Abus e Prevention A ct]

YOU MUST PROVIDE COMPLETE AND TRUTHFUL INFORMATION. IF YOU DO NOT, THE COURT MAY DISMISS ANY RESTRAINING ORDER AND MAY ALSO HOLD YOU IN CONTEMPT OF COURT. If you wish to have your residential address or telephone number withheld from respondent, use a contact address and telephone number so the court and the sheriff can reach you if necessary. ATTACH ADDITIONAL PAGES IF NECESSARY. (Check one): I am the Petitioner and reside in Linn County, state of Oregon. I state that the information provided below is true.

I am the Guardian Petitioner. The elderly person or person with disabilities on
whose behalf I am filing this petition is (Name)_________________________________ who is a resident of Linn County, state of Oregon. I am the guardian guardian ad litem for the named elderly person or person with disabilities. I state that the information provided below is true. GUARDIAN PETITIONERS: THROUGHOUT THIS FORM, INFORMATION IS PROVIDED FOR AND REQUESTED ABOUT THE ELDERLY OR DISABLED PERSON YOU REPRESENT. AS A GUARDIAN PETITIONER, YOU ARE TO PROVIDE INFORMATION, NOT ABOUT YOURSELF, BUT ABOUT THE ELDERLY OR DISABLED PERSON ON WHOSE BEHALF YOU ARE SEEKING A RESTRAINING ORDER. Provide information about yourself as "guardian petitioner" only where specifically requested. Respondent is a resident of __________________ County, State of _____________.

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Check and fill out the section that applies to you: I am 65 years of age or older. I am years of age. I am a person with disabilities. Explain the nature of the mental or physical disability: ______________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 1. CHECK AND FILL OUT OR CIRCLE ANY SECTION(S) that apply to you and respondent. A. Respondent and I have been living together since _____________. B. Respondent and I lived together from ________to ____________. C. I have been under the care of respondent since ______________ . D. I was under the care of respondent from ______ to ___________ . E. None of the above. 2. To qualify for a restraining order, respondent must have done one or more of the following: Within the last 180 days, respondent has: A. Caused me physical injury by other than accidental means. B. Attempted to cause me physical injury by other than accidental means. C. Caused me physical harm by withholding services necessary to maintain my health and well-being. D. Abandoned or deserted me by withdrawing or neglecting to perform duties and obligations. E. Willfully inflicted me with physical pain or injury. F. Used derogatory or inappropriate names, phrases or profanity, ridicule, harassment, coercion, threats, cursing, intimidation or inappropriate sexual comments or conduct of such a nature as to place me in fear of significant physical or emotional harm. 3. Any period of time after the abuse occurred during which respondent was incarcerated (in jail or prison) or lived more than 100 miles from your home is not counted as part of the 180-day period, and you may still be eligible for a restraining order. Respondent was incarcerated from ______________________ to ______________________. Respondent lived more than 100 miles from my home from ______________________ to ______________________. 4. Did the abuse happen within the last 180 days not including the times respondent was incarcerated (in jail or prison) or lived more than 100 miles from your home? Yes No (Circle one) Date and location of abuse: ______________________________________________ How did respondent injure or threaten to injure you? ___________________________ _____________________________________________________________________
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____________________________________________________________________. 5. Are there incidents other than those described in question 4. above in which respondent injured or threatened to injure you? If yes, explain: _____________________________________________________________________ _____________________________________________________________________ 6. The abuse I am complaining about was witnessed by ________________________________________________________________ ________________________________________________________________ ____________ (affidavit attached). Other persons with knowledge of the abuse are _____________________________________________________________ ________________________________________________________________ ____________ (affidavit attached). I am in immediate and present danger of further abuse by respondent because: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ In any of the above incidents: Were drugs, alcohol, or weapons involved? Yes No (Circle one) Did you need medical help? Yes No (Circle one) Were the police or the courts involved? Yes No (Circle one) If you have circled yes to any of the above questions, explain: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ A.

7.

8.

9.

There (is) (is not) another Elderly Persons and Persons With Disabilities Abuse Prevention Act or Family Abuse Prevention Act proceeding pending between respondent and me. It is filed in ____________________ (County), ____________________ (State), and I am, the (Petitioner) or (Respondent) in that case (circle one). The case number of the case is: ____________________ B. There (is) (is not) another lawsuit pending between respondent and me for divorce, annulment, or legal separation. If yes, type of lawsuit: ____________________. It is filed in ____________________ (County), ____________________ (State). 10. Respondent may be required to move from your residence if: (a) it is in your sole name; (b) if it is jointly owned or rented by you and respondent; or (c) if you and respondent are married. I (do) (do not) want respondent to move from my residence. My residence is: Owned Leased Rented By: ____________________ _______________________(Name)

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PETITIONER/GUARDIAN PETITIONER ASKS THE COURT TO GRANT THE RELIEF INDICATED IN THE "PETITIONER'S/GUARDIAN PETITIONER'S REQUEST" COLUMN OF THE PROPOSED RESTRAINING ORDER, WHICH IS ATTACHED. PETITIONER/GUARDIAN PETITIONER MUST NOTIFY THE COURT OF ANY CHANGE OF ADDRESS.ALL NOTICES OF HEARING WILL BE SENT TO THIS ADDRESS AND DISMISSALS MAY BE ENTERED IF THE PETITIONING PARTIES DO NOT APPEAR AT A SCHEDULED HEARING. If you wish to have a residential address or telephone number withheld from respondent, use a contact address and contact telephone number so the court and the sheriff can reach you if necessary. Signature of Petitioner Guardian Petitioner ________________________________ Print or Type Name of Petitioner Guardian Petitioner STATE OF OREGON ) ) ss. County of _________________ )

SUBSCRIBED AND SWORN TO before me this __________ day of _____________, 20____, by ___________________________________. (Print Name of Petitioner/Guardian Petitioner)

________________________________ NOTARY PUBLIC FOR OREGON/COURT CLERK My commission expires: _______________________ 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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