Protected: Date of Birth of Protected Person




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STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY

For Official Use


Name of Person to be

Protected:


Date of Birth of Protected Person:
Name of Petitioner

(if different from Protected Person):



     


     

     


Petition in

Juvenile Court for

Temporary Restraining Order and/or Petition and Motion for Injunction Hearing
(Harassment – 30711)






-vs.-




Respondent/

Defendant:



     

Address:

     

     

Case No.      



If there is a CHIPS proceeding involving the child or the respondent is a minor, use this form.




Respondent’s:

Sex

     


Race

     


Date of Birth

     


Height

     


Weight

     


Hair color

     


Eye color

     


Please specify Petitioner’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]      


Respondent’s Distinguishing Features:

(such as scars, marks or tattoos)

     
 None known.


CAUTION:

(Check all that apply)

 Respondent 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 petitioner (child).








I petition the court for a temporary restraining order and/or injunction against the respondent under §813.125, Wisconsin Statutes, based on the following:

1. [Name of Person to be Protected]       , is the alleged victim of harassment.


2. Stated below or attached as part of this petition is a statement of facts indicating that respondent has engaged in conduct which is believed to be harassment.

(Harassment is defined as: (a) Striking, shoving, kicking or otherwise subjecting the person to physical contact; or (b) Engaging in an act that would constitute child abuse under §48.02(1); or (c) Sexual assault under §940.225; or (d) Stalking under §940.32; or attempts or threat to do same; or (e) Engaging in a course of conduct or repeatedly committing acts which harass or intimidate the person and which serve no legitimate purpose.)

(State when, where, what happened, and who did what to whom)  See attached

     


3. Another no contact order between the person to be protected and the respondent

 does not exist or the petitioner/ person to be protected does not know or is uncertain as to whether another no contact order exists.

 does exist.

Name of other case:     

County or State: [If not Wisconsin]      

Type of Case:      

Case Number: [If known]      

Date of proceeding that resulted in no contact order: [If known]      

Details of no contact order:      


8. If the respondent is the parent or legal guardian of the child or has court-ordered visitation with the child, the petitioner must complete the Uniform Child Custody Jurisdiction and Enforcement Act Affidavit form (GF-150), which the clerk shall keep confidential and not disclose to the respondent.
I REQUEST THE COURT: [Mark any of the following boxes that apply.]

 1. Issue a temporary restraining order requiring the respondent to

 a. cease or avoid harassing the person to be protected.

 b. avoid the person to be protected residence and/or any premises temporarily occupied by the person to be protected.

 c. avoid contact that harasses or intimidates the person to be protected. Contact includes: contact at person to be protected home, work, school, public places, in person, by phone, in writing, by electronic communication or device, or in any other manner.

 d. The respondent refrain from removing, hiding, damaging, harming, or mistreating, or disposing of, a household pet.

 e. The respondent allow the petitioner or a family member or household member of the petitioner acting on his/her behalf to retrieve a household pet.

 f. Other: [List other specific behavior the petitioner/person to be protected wants the respondent to stop doing.]      



 2. Set a time for a hearing on the petition for an injunction requiring the respondent to

 a. cease or avoid harassing the person to be protected.

 b. avoid the person to be protected residence and/or any premises temporarily occupied by the person to be protected.

 c. avoid contact that harasses or intimidates the person to be protected. Contact includes: contact at person to be protected home, work, school, public places, in person, by phone, in writing, by electronic communication or device, or in any other manner.

 d. The respondent refrain from removing, hiding, damaging, harming, or mistreating, or disposing of, a household pet.

 e. The respondent allow the petitioner or a family member or household member of the petitioner acting on his/her behalf to retrieve a household pet.

 d. Other: [List other specific behavior the petitioner/person to be protected wants the respondent to stop doing.]      



 3. If the temporary restraining order is denied, the petitioner/ person to be protected asks the court to schedule an injunction hearing.


If the temporary restraining order is denied, the person to be protected is only entitled to an injunction hearing if the petition alleges conduct that is the same as or similar to conduct that is prohibited under §940.32 [stalking]; or is the intentional infliction of physical pain, physical injury or illness; or is an intentional impairment of physical condition; or is a violation of §940.225(1), (2) or (3) [sexual assault]; or is a violation of §943.01 involving destruction of property that belongs to the individual; or is a threat to engage in the above mentioned behavior.
4. Issue an injunction against the respondent for four years or the following shorter period      
 5. Order the injunction, which is in effect for not more than 10 years, if the court finds a substantial risk the respondent may commit 1st or 2nd degree intentional homicide, or 1st, 2nd or 3rd degree sexual assault against the petitioner.
6. If the court grants the injunction, the petitioner requests the court

 1. not order the respondent to surrender his/her firearm(s). OR

 2. order the respondent to surrender and not possess a firearm while the injunction is in effect because the petitioner believes that the respondent may use a firearm to cause physical harm to another or endanger public safety.
 7. Direct the sheriff to assist in executing or serving this petition for temporary restraining order and/or petition and motion for injunction hearing, if requested.
The petitioner must have the sheriff’s office or other process server serve the documents on the respondent. Before the injunction hearing, it is the petitioner’s responsibility to contact the sheriff’s office or other process server to verify that the documents were served and proof of service is filed with the Clerk of Circuit Court. The court will not do this for the petitioner.
If the respondent cannot be personally served with the Petition in Juvenile Court for Temporary Restraining Order and/or Petition and Motion for Injunction Hearing: Harassment (JV-1693) form, the respondent can be served by publication using Publication Notice form (CV-505). The petitioner/person to be protected must file with the court an affidavit stating that service of the respondent by the sheriff or a private process server was unsuccessful because the respondent was avoiding service by concealment or otherwise. The petitioner/person to be protected should get this affidavit from the sheriff or private process server. 
The petitioner/person to be protected also must send the Petition in Juvenile Court for Temporary Restraining Order and/or Petition and Motion for Injunction Hearing form to the respondent via mail or facsimile and must provide proof of transmission (e.g. certified mail receipt, affidavit of mailing or faxing). The mailing or sending of a facsimile may be omitted if the post-office address or facsimile number cannot be ascertained with due diligence.
IF the petitioner chooses service by publication, the Notice in the newspaper is public information and will include the petitioner’s name and address which is otherwise kept confidential. 
 8. Direct the sheriff to accompany the petitioner/person to be protected and assist in placing the petitioner/person to be protected in physical possession of his or her residence, if requested.





*I am:  An adult filing on behalf of a child involved in a CHIPS proceeding. My relationship to the child is       .

 An adult filing on behalf of a child and the respondent is a child.

My relationship to the child is:       .

 A child petitioner involved in a CHIPS proceeding.

 A child petitioner and the respondent is a child.

 An adult petitioner and the respondent is a child.




State of      

County of      

Subscribed and sworn to before me on      



Notary Public/Court Official

     

Name Printed or Typed

My commission/term expires:      






Signature of Person Completing the Petition
     

Name Printed or Typed
     

Date




Distribution:

1. Original - Court

2. Person to be Protected

3. Person filing on behalf of the Person to be Protected

4. Respondent

5. Guardian ad Litem(if any)

6. Law Enforcement

7. Other:      


CONFIDENTIAL COURT RECORD

JC-1693, 02/16 Petition in Juvenile Court for Temporary Restraining Order and/or Petition and Motion for Injunction Hearing (Harassment)



§§48.25(6) and 813.125, Wisconsin Statutes

This form shall not be modified. It may be supplemented with additional material.

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