INSTRUCTIONS FOR FILING AN AFFIDAVIT OF VIOLATION

OF INJUNCTION FOR PROTECTION AGAINST

EXPLOITATION OF A VULNERABLE ADULT

When should this form be used?

This form may be used to notify the court, state attorney, and law enforcement of a violation of

an injunction for protection against exploitation of a vulnerable adult. A respondent may violate

such an injunction by:

or indirectly where the injunction does not specifically allow indirect contact through a

third party;

• Knowingly and intentionally coming within 100 feet of the vulnerable adult's motor

vehicle, regardless of whether that vehicle is occupied; or

• Defacing or destroying the vulnerable adult's personal property.

Who may file this form?

exploitation of a vulnerable adult.

v. Case No.: _____________________

Division: _____________________

_________________________________,

Respondent

/

AFFIDAVIT OF VIOLATION OF INJUNCTION

AGAINST EXPLOITATION OF A VULNERABLE ADULT

Respondent has violated the Injunction Against Exploitation of a Vulnerable Adult

entered on ________________, 20__ , in the above-styled action, by (check all that apply):

___ Refusing to vacate the dwelling respondent shares with the vulnerable adult;

___ Going to or being within 500 feet of the vulnerable adult's residence;

___ Exploiting or unduly influencing the vulnerable adult;

___ Committing any other violation of the injunction through an intentional unlawful

___ Knowingly and intentionally coming within 100 feet of the vulnerable adult's

motor vehicle, regardless of whether that vehicle is occupied; or

___ Defacing or destroying the vulnerable adult's personal property.

The following lines may be used to explain any alleged violation:

AFFIANT HEREBY CERTIFIES UNDER PENALTY OF PERJURY THAT THE

STATEMENTS AND FACTS IN THIS AFFIDAVIT ARE TRUE AND CORRECT TO

Sworn to or affirmed and signed before me on , 20 , by .