Illinois > Local County > Champaign > Domestic Violence
Verified Petition For Order Of Protection - Illinois
| Verified Petition For Order Of Protection Form. This is a Illinois form and can be used in Domestic Violence Champaign Local County . |
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CIRCUIT COURT OF ILLINOIS Sixth Judicial Circuit Champaign County Petitioner's Name (Person desiring protection) I am filing on behalf of: myself and/or minor child(ren) dependent high risk adult (as listed below): vs. Respondent's Name (Person you desire protection from) Independent Criminal Juvenile Other Civil Proceeding (file stamp) Case # Case # (file stamp) VERIFIED PETITION FOR ORDER OF PROTECTION I request an Order of Protection against (Name of Respondent) . 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. 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: ______________ (mmddyyyy) Social Security Number: XXX-XXWeight: Height: ft. Respondent's Current Address: (Street / P.O. Box) (City) (State) (Zip Code) Unknown in. Sex: Male Female Race: Eye color: (last 4 numbers) Hair color: Respondent's Work Address: (Street / P.O. Box) Work Hours: _________________________ (City) (State) (Zip Code) Distinguishing Features (scars, marks, tattoos, etc.): Driver's License #: _________________________ License Plate #:______________________ Page 1 of 11- Verified Petition for Order of Protection Revised: 12/12 Form approved by the Conference of Chief Circuit Judges. Clerk Effective 11-1-04 / Use Required after 7-1-05 Katie M. Blakeman of the Sixth Judicial Circuit Court 101 E. Main Street Urbana, Illinois 61801 American LegalNet, Inc. www.FormsWorkFlow.com RELATIONSHIP CODE The Petitioner/Abused PersonCIRCUIT the following ILLINOIS stands in COURT OF relationship to (check all that apply): Sixth RELATIONSHIP RELATIONSHIP Judicial Circuit Spouse (SE) Parent (PA) Champaign County 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 Respondent St/County Case Number Name of Petitioner Date of expiration (mmddyyyy) 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 Respondent St/County Case Number Name of Petitioner Date of expiration (mmddyyyy) 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. Page 2 of 11- Verified Petition for Order of Protection Form approved by the Conference of Chief Circuit Judges. Effective 11-1-04 / Use Required by 7-1-05 Katie M. Blakeman Clerk of the Sixth Judicial Circuit Court 101 E. Main Street Urbana, Illinois 61801 American LegalNet, Inc. www.FormsWorkFlow.com 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 CIRCUIT COURT OF ILLINOIS Date(s) Description of Sixth Judicial Circuit Incident(s) Champaign County abuse had on you, and the date and place that each incident occurred. Attach additional pages, if necessary) Continued on attached page(s) Page 3 of 11- Verified Petition for Order of Protection Form approved by the Conference of Chief Circuit Judges. Effective 11-1-04 / Use Required by 7-1-05 Katie M. Blakeman Page 3 of 11 Petition Clerk of the Sixth Judicial Circuit Court 101 E. Main Street Urbana, Illinois 61801 American LegalNet, Inc. www.FormsWorkFlow.com REMEDIES SECTION CIRCUIT(750 ILCS 60/214) COURT OF ILLINOIS PURSUANT TO THE ILLINOIS DOMESTIC VIOLENCE ACT ("THE ACT"), THE Sixth REMEDIES: PETITIONER SEEKS THE FOLLOWING Judicial Circuit Champaign County 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) Stay Away a. That the Respondent be ordered to stay at least _____ feet away from the Petitioner and/or protected person(s)' and their residence, school, daycare, employment and any other specified place. "Stay Away" means for the Respondent to refrain from both physical presence and non-physical 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. b. 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 of employment at ________________________
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