Fill and Sign the Vulnerable Adult Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use Injunction (Individual at Risk)Petitioner:       Date of Birth:       -VS- Respondent:       Address:             Case No.       Respondent’s: Date of Birth Sex Race Height Weight Hair color Eye Color                                           THE COURT FINDS: 1. The petitioner has filed a petition alleging the elements under §813.123(6), Wis. Stats. 2. The respondent has been properly served with a copy of the petition and notice of the time for hearing on the issuance of an injunction. The respondent had an opportunity to be heard. The court has personal and subject matter jurisdiction. 3. Based on the hearing held on the petition, there are reasonable grounds to believe any of the following: The respondent has interfered with, or based on prior conduct of the respondent, may interfere with, an investigation of the individual at risk and that the interference complained of, if continued, would make it difficult to determine if 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 is occurring or may recur. The respondent has interfered with the delivery to the individual at risk of protective services or a protective placement of the individual at risk after the offer of protective services or protective placement has been made and the individual at risk or his or her guardian, if any, has consented to receipt of the protective services or protective placement; or that the respondent has interfered with the delivery of services to an elder adult at risk. The respondent engaged in or threatened 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. THE COURT ORDERS THE RESPONDENT TO: 1. Avoid interference with an investigation of the individual at risk, the delivery of protective services to the individual at risk, or a protective placement of the individual at risk, or the delivery of services to the elder adult at risk. 2. 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 an individual at risk, or mistreatment of an animal. 3. 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 adult at risk, except as otherwise provided for in this order. (Note: This is not to be ordered unless either #$1 or #2 above have been ordered.) 4. Avoid the residence of the individual at risk or any other location temporarily occupied by the individual at risk, or both. CV-430, 10/06 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 Injunction (Individual at Risk) Page 2 of 3 Case No. 5. Avoid contacting or causing any person other than a party’s attorney or a law enforcement officer to contact the individual at risk. 6. Engage in any other appropriate remedy not inconsistent with the remedies requested in the petition, such as:       THIS INJUNCTION SHALL BE EFFECTIVE UNTIL       (Not to exceed 4 years) Violation of this order shall result in a fine of not more than $1,000 or imprisonment for not more than 9 months or both. Violation of this injunction shall result in your arrest and may result in the imposition of criminal penalties, regardless of whether you have been served a copy of the injunction. This injunction is entitled to full faith and credit in every civil or criminal court of the United States, civil or criminal courts of any other state, and Indian tribal courts to the extent such courts may have personal jurisdiction over nontribal members. CV-430, 10/06 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 The respondent was present in court and personally served with a copy of this order. DISTRIBUTION: 1. Original - Court 2. Petitioner 3. Respondent 4. Law Enforcement BY THE COURT: Circuit Court Judge       Name Printed or Typed       Date CV-430 10/06 Injunction (Individual at Risk) §813.123, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2