Fill and Sign the Restraining Order and 497430839 Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use Petition for Temporary Restraining Order and/or Injunction (Individual at Risk - 30713)Petitioner:       Date of Birth:       -vs- Respondent:       Address:             Case No.       Respondent’s: Date of Birth Sex Race Height Weight Hair color Eye Color                                           Under oath, I petition the court for a temporary restraining order and/or injunction against the respondent under §813.123, Wisconsin Statutes, based on the following: 1 . I am: a. an adult at risk (an adult who has a physical or mental condition that substantially impairs his/her ability to care for his/her needs and who has experienced, is currently experiencing, or is at risk of experiencing physical abuse, emotional abuse, sexual abuse, treatment without consent, unreasonable confinement or restraint, neglect, self-neglect, or financial exploitation). b. an elder adult at risk (a person age 60 or older who has experienced, is currently experiencing, or is at risk of experiencing physical abuse, emotional abuse, sexual abuse, treatment without consent, unreasonable confinement or restraint, neglect, self-neglect, or financial exploitation). c. acting on behalf of an individual at risk, an adult-at-risk agency, or an elder-adult-at-risk agency. 2. The name of the individual at risk (an adult who is an elder adult at risk or adult at risk) is:       3. The name of the petitioner is:       . 4. The name of the adult respondent is:       5. The adult respondent has: (Mark any of the following boxes that apply) a. interfered with, or based upon prior conduct of the respondent, may interfere with: 1. An investigation of the individual at risk; or 2. The delivery of protective services to the individual at risk; or 3. A protective placement of the individual at risk; or 4. The delivery of services to the elder adult at risk. and that the interference complained of, if continued, would make it difficult to determine whether physical abuse, emotional abuse, sexual abuse, treatment without consent, unreasonable confinement or restraint, financial exploitation, neglect, or self-neglect has occurred, is occurring, or may recur. OR CV-428 , 10/06 Petition for Temporary Restraining Order and/or Injunction (Individual at Risk) §813.123, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 3 Petition for Temporary Restraining Order and/or Injunction (Individual at Risk) Page 2 of 3 Case No. b. engaged in or threatened to engage in with the individual at risk: physical abuse. emotional abuse. sexual abuse. treatment without consent. unreasonable confinement or restraint financial exploitation. neglect. harassment. stalking. mistreatment of an animal. 6. Stated below or attached as part of this petition is a statement of facts indicating that respondent has met the criteria set forth in either or both 5.a. or 5.b. above: (State when, where, what happened, and who did what to whom:) See attached       I REQUEST THAT THE COURT: (Mark any of the following that apply) 1. Issue a temporary restraining order requiring the respondent to: a. Avoid interference with an investigation of the individual at risk. b. Avoid interference with the delivery of protective services to the individual at risk. c. Avoid interference with a protective placement of the individual at risk. d. Avoid interference with the delivery of services to the elder adult at risk. e. Cease engaging in or threatening to engage in physical abuse, emotional abuse, sexual abuse, treatment without consent, unreasonable confinement or restraint, financial exploitation, neglect, harassment, or stalking of the individual at risk, or mistreatment of an animal. f. Avoid the residence of the individual at risk or any other location temporarily occupied by the individual at risk, or both. g. Avoid contacting or causing any person other than a party’s attorney or a law enforcement officer to contact the individual at risk. h. Other: (any other appropriate remedy not inconsistent with the remedies requested in the petition)       CV-428 , 10/06 Petition for Temporary Restraining Order and/or Injunction (Individual at Risk) §813.123, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 3 Petition for Temporary Restraining Order and/or Injunction (Individual at Risk) Page 3 of 3 Case No. 2. Set a time for a hearing on the petition for an injunction requiring the respondent to: a. Avoid interference with an investigation of the individual at risk. b. Avoid interference with the delivery of protective services to the individual at risk. c. Avoid interference with a protective placement of the individual at risk. d. Avoid interference with the delivery of services to the elder adult at risk. e. Cease engaging in or threatening to engage in physical abuse, emotional abuse, sexual abuse, treatment without consent, unreasonable confinement or restraint, financial exploitation, neglect, harassment, or stalking of the individual at risk, or mistreatment of an animal. f. Avoid the residence of the individual at risk or any other location temporarily occupied by the individual at risk, or both. g. Avoid contacting or causing any person other than a party’s attorney or a law enforcement officer to contact the individual at risk. h. Other: (any other appropriate remedy not inconsistent with the remedies requested in the petition)       3. Direct the sheriff to serve and assist in executing this petition and temporary restraining order. 4. Appoint a guardian ad litem for the individual at risk. (The court shall order and appoint a guardian ad litem if the petition was filed by a person other than the individual at risk.) 5. Enter an injunction for four years or the following shorter period:       DISTRIBUTION: 1. Original - Court 2. Petitioner 3. Respondent 4. Law Enforcement Subscribed and sworn to before me on       Notary Public, State of Wisconsin My commission expires:       Signature of Petitioner       Date CV-428 , 10/06 Petition for Temporary Restraining Order and/or Injunction (Individual at Risk) §813.123, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 3