Fill and Sign the Petitioner Individual at Risk Form

CV-430, 05/16 Injunction (Order of Protection – Individual at Risk) §813.123, W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 3 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Amended INJUNCTION – Individual at Risk (Order of Protection - 30713) Case No. PETITIONER (INDIVIDUAL AT RISK) Name of Petitioner (First, Middle, Last) Date of Birth of Individual at Risk -VS.- RESPONDENT/DEFENDANT 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] involving the individual at risk. 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 4 years or 10 years under §813.123(5)(d), W is. Stats. NOTIFICATIONS/WARNINGS TO RESPONDENT/DEFENDANT: This order shall be enforced, even without registration, and is entitled to full faith and credi t 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; W is. Stats. 813.128). Crossing state, territorial, or tribal boundaries to violate this order ma y result in federal imprisonment (18 U.S.C. Section 2262). Federal law provides penalties for, and you may be prohibited from possessing, transpo rting, shipping, receiving, or purchasing a firearm, including, but not limited to, a rifle, shotgun, pistol, revolver, or ammunition, pursuant t o 18 U.S.C. Section 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 impris onment 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. Name of Respondent/Defendant (First, Middle, Last ) Respondent’s/Defendant’s Street Address, City, State, Zip Please specify Individual at Risk’s relationship(s) to Respondent/Defendant: spouse cousin adoptive parent former spouse sibling grandparent person in dating relationship parent child (biological/adoptive/step) current or former live- in step parent relationship Other: [Be specific] SEX RACE DOB HT WT HAIR COLOR EYE COLOR Respondent’s/Defendant’s Distinguishing Features (such as scars, marks or tattoos) None known. CAUTION: (Check all that apply) Injunction (Order of Protection - Individual at Risk) Page 2 of 3 Case No. CV-430, 05/16 Injunction (Order of Protection- Individual at Risk) §813.123, W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 3 THE COURT FINDS: 1. T he individual at risk or person/agency on behalf of the individual at risk filed a p etition alleging the elements under §813.123(6), W is. Stats. 2. This court has personal and subject matter jurisdiction. The respondent has been properly served and had an opportunity to be heard. 3. There are reasonable grounds to believe that the respondent has interfered with, engaged in or bas ed on prior conduct of the respondent, may engage in abuse as defined in §813.123, Wis. Stats., as stated in t he court record. 4. The name of the individual at risk [an adult who is an elder adult at risk or adult at risk] is . 5. The name of the person who filed on behalf of the individual at risk is . * 6. There is is not clear and convincing evidence that the respondent may use a firearm to cause phy sical harm to another or to endanger public safety. 7. There is a substantial risk the respondent may commit 1 st degree intentional homicide under §940.01, Wis. Stats., 2 nd degree intentional homicide under §940.05, Wis. Stats., 1 st , 2 nd , or 3 rd degree sexual assault under §940.225(1), (2) or (3), W is. Stats., or 1 st or 2 nd degree sexual assault under §948.02(1) or (2), W is. Stats., against the petitioner resulting in an injunction order for not more than 10 years. 8. The respondent was present in court and personally served with a copy of this order. 9. The respondent was present in court and personally served with a copy of the Order to Surr ender Firearms and Notice of Firearm Surrender Hearing (CV-803). 10. The petitioner has requested the wireless telephone service provider transfer to the peti tioner each telephone number(s) he/she or a minor child in his/her custody uses. THE COURT ORDERS: 1. The respondent to avoid interference with an investigation of the individual at ris k, the delivery of protective services to the individual at risk, or a protective placement of the individual at risk, o r the delivery of services to the elder adult at risk. 2. The respondent to cease engaging in or threatening to engage in the physical abuse, emotional abuse, sexual abuse, treatment without consent, unreasonable confinement or restraint, financial explo itation, neglect, harassment, stalking o f the individual at risk, or the mistreatment of an animal. 3. The respondent to avoid the residence of the individual at risk and/or any other location temporarily occupied by the individual at risk. 4. The respondent to avoid contacting the individual at risk or causing any person other than a party’s attorney or a law enforcement officer to contact the individual at risk. Contact includes: contact at individual at risk’s home, work, school, public places, in person, by phone, in writing, by electronic communicatio n or device, or in any other manner. 5. The respondent refrain from removing, hiding, damaging, harming, or mistrea ting, or disposing of, a household pet. 6. The respondent allow the petitioner or a family member or household member of the petit ioner acting on his/her behalf to retrieve a household pet. Injunction (Order of Protection - Individual at Risk) Page 3 of 3 Case No. CV-430, 05/16 Injunction (Order of Protection- Individual at Risk) §813.123, W isconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 3 7. The respondent to not intentionally prevent a representative or employee of the county protective services agency from meeting, communicating, or being in visual or audio contact with the individual at risk, except as ordered here: 8. The wireless telephone service provider to transfer, within 72 hours of receipt of the order, to the petitioner each telephone number(s) he/she or a minor child in his/her custody uses . (See Wireless Telephone Service Transfer Order in Injunction Case (CV-437) for more details.) 9. Other: [May not be inconsistent with remedies requested in the petition .] THE COURT FURTHER ORDERS: *[This order only applies if finding #6 above has been checked and the court has found by clear and convincing evidence that t he respondent may use a firearm to cause physical harm to another or to endanger public safety.] 1. The respondent is prohibited from possessing a firearm until the expiration of this inj unction. 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. The respondent shall immediately surrender any firearm(s) that he or she owns or has in his or h er possession to the sheriff of this county. the sheriff of the county in which the respondent resides: . another person. [Name and Address] . Note: Court shall complete the Notice of Firearms Possession Penalties ( CV-432). 2. The respondent shall surrender firearms pursuant to Order to Surrender Firearms and Notice of Firearm Surrender Hearing (CV-803). 3. The respondent was not present in court and shall be served a copy of Notice of Firearm S urrender Hearing (CV -802). THIS IS A FINAL ORDER FOR PURPOSES OF APPEAL. BY THE COURT: DISTRIBUTION: 1. Court 2. Petitioner (Individual at Risk) 3. Person/Agency acting on behalf of the Individual at R isk 4. Respondent 5. Guardian ad Litem (if appointed) 6. Law Enforcement 7. Other: Circuit Court Judge Title (Print or Type Name if not eSigned) Date