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IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL (Pinellas County Clerk of the Circuit Court and Comptroller)

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Page 1 of 6
IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT OF THE STATE OF
FLORIDA IN AND FOR PINELLAS COUNTY
IN RE:
______________________________,
Alleged Vulnerable Adult,
______________________________,
Petitioner,
v. Case Number: _______________
UCN: ______________________
Division: ___________________
_____________________________,
Respondent.
____________________________________/
PETITION FOR INJUNCTION FOR PROTECTION
AGAINST EXPLOITATION OF VULNERABLE ADULT
Before me, the undersigned authority, personally appeared the Petitioner (Name) who has been
sworn and says that the following statements are true:
SECTION I: ALLEGED VULNERABLE ADULT
(This section is about the Alleged Vulnerable Adult. It must be completed.)
1. The Alleged Vulnerable Adult’s name and date of
birth:___________________________________________________________________
2. The Alleged Vulnerable Adult resides at: {street address}
_______________________________________________________________________
{city, state, and zip code} __________________________________________________
Telephone Number: {area code and number} __________________________________
3. The relationship between the Alleged Vulnerable Adult and the Petitioner:
________________________________________________________________________
4. The relationship between the Alleged Vulnerable Adult and the Respondent:
________________________________________________________________________
SECTION II: PETITIONER
1. Petitioner’s contact information: _________________________________
Page 2 of 6
Telephone number: {area code and number} ___________________________________
2. Petitioner’s attorney’s name, address, and telephone number:
________________________________________________________________________
(If the Petitioner does not have an attorney, write “none”.)
SECTION III: RESPONDENT
(This section is about the person you want the Alleged Vulnerable Adult to be protected from. It
must be completed.)
1. The Respondent resides at: {last known address}
________________________________________________________________________
2. The Respondent’s last known place of employment is: {name of business and address}
_______________________________________________________________________
Working hours: __________________________________________________________
3. Physical description of the Respondent:
________________________________________________________________________
Race: _______ Sex: Male _______ Female: _______ Date of birth: _________________
Height: _______ Weight: _______ Eye color: _______ Hair color: __________________
Distinguishing marks or scars: _______________________________________________
4. Aliases of the Respondent {nicknames or other names the Respondent goes by}:
________________________________________________________________________
5. Respondent’s attorney’s name, address, and telephone number:
________________________________________________________________________
(If you do not know whether the Respondent has an attorney, write “unknown”. If the
Respondent does not have an attorney, write “none”.)
SECTION IV: CASE/REPORT HISTORY AND REASON FOR SEEKING PETITION
(This section must be completed.)
1. The Respondent is associated with the Alleged Vulnerable Adult as follows:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. The following describes any other cause of action currently pending between the
Petitioner and the Respondent, any proceeding under chapters 393 and 744 concerning
the Alleged Vulnerable Adult, and any previous or pending attempts by the Petitioner to
obtain an injunction for protection against exploitation of the Alleged Vulnerable Adult
in this or any other circuit; related case numbers, if available, and the results of any such
attempts:
Page 3 of 6
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. The following describes the Petitioner’s knowledge of any reports made to a law
enforcement or government agency, including, but not limited to, the Department of
Elderly Affairs, the Department of Children and Families, and the adult protective
services program relating to the abuse, neglect, or exploitation of the Alleged Vulnerable
Adult; any investigations performed by a government agency relating to abuse, neglect,
or exploitation of the Alleged Vulnerable Adult, and the results of any such reports or
investigations:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4. The Petitioner knows the Alleged Vulnerable Adult is either a victim of exploitation or
the Petitioner has reasonable cause to believe the Alleged Vulnerable Adult is, or is in
imminent danger of becoming, a victim of exploitation because the Respondent has:
{describe in the spaces below the incidents or threats of exploitation}:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
5. The following describes the Petitioner’s knowledge of the Alleged Vulnerable Adult’s
dependence on the Respondent for care; alternative provisions for the Alleged Vulnerable
Adult’s care in the absence of the Respondent, if necessary; available resources the
Alleged Vulnerable Adult has to access such alternative provisions; and the Alleged
Vulnerable Adult’s willingness to use such alternative provisions:
________________________________________________________________________
Page 4 of 6
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
6. The Petitioner knows the Alleged Vulnerable Adult maintains assets, accounts, or lines of
credit at the following financial institution(s): {list name, address, and account number of
each}:
Name of Financial Institution Address Account Number
a. ________________________________________________________________________
b. ________________________________________________________________________
c. ________________________________________________________________________
d. ________________________________________________________________________
e. ________________________________________________________________________
7. The Petitioner believes that the Alleged Vulnerable Adult’s assets to be frozen are: {mark
one}
Worth less than $1,500;
Worth between $1,500 and $5,000; or
Worth more than $5,000.
8. The Petitioner genuinely fears imminent exploitation for the Alleged Vulnerable Adult by
the Respondent.
SECTION IV: REQUEST FOR INJUNCTION
(This section must be completed.)
1. The Petitioner seeks an injunction for the protection of the Alleged Vulnerable Adult,
including: {mark appropriate section or sections}
Prohibiting the Respondent from having any direct or indirect contact with the
Alleged Vulnerable Adult.
Immediately restraining the Respondent from committing any acts of exploitation
against the Alleged Vulnerable Adult.
Page 5 of 6
Freezing the assets of the Alleged Vulnerable Adult held at {name and address of
depository or financial institution}______________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
even if titled jointly with the Respondent, or in the Respondent’s name only, in
the court’s discretion.
Freezing the credit lines of the Alleged Vulnerable Adult at {name and address of
financialinstitution}_________________________________________________
__________________________________________________________________
__________________________________________________________________
even if titled jointly with the Respondent, in the court’s discretion.
Providing any terms the court deems necessary for the protection of the Alleged
Vulnerable Adult or his or her assets, including any injunctions or directives to
law enforcement agencies.
Suspend durable power of attorney
2. Should the court enter an injunction freezing assets and credit lines, the Petitioner
believes that the critical expenses of the Alleged Vulnerable Adult will be paid for or
provided by the following persons or entities, or the Petitioner requests that the
following expenses be paid notwithstanding the freeze: {for each expense, list the name
of the payee, address, account number if known, amount, and a brief explanation of why the
payment is critical}
Payee Name Address Acct. No. Amount Explanation
a. ________________________________________________________________________
b. ________________________________________________________________________
c. ________________________________________________________________________
d. ________________________________________________________________________
e. ________________________________________________________________________
I ACKNOWLEDGE THAT PURSUANT TO SECTION 415.1034, FLORIDA STATUTES,
ANY PERSON WHO KNOWS, OR HAS REASONABLE CAUSE TO SUSPECT, THAT
A VULNERABLE ADULT HAS BEEN OR IS BEING ABUSED, NEGLECTED, OR
EXPLOITED HAS A DUTY TO IMMEDIATELY REPORT SUCH KNOWLEDGE OR
SUSPICION TO THE CENTRAL ABUSE HOTLINE. I HAVE REPORTED THE
ALLEGATIONS IN THIS PETITION TO THE CENTRAL ABUSE HOTLINE.
Page 6 of 6
I HAVE READ EACH STATEMENT MADE IN THIS PETITION AND EACH
STATEMENT IS TRUE AND CORRECT. I UNDERSTAND THAT THE STATEMENTS
MADE IN THIS PETITION ARE BEING MADE UNDER PENALTY OF PERJURY
PUNISHABLE AS PROVIDED IN SECTION 837.02, FLORIDA STATUTES.
___________
(Initials)
Dated: ______________________ ____________________________________
Signature of Petitioner
STATE OF FLORIDA
COUNTY OF ______________
Sworn to or affirmed and signed before me on this _______ day of ________________, 20____,
by _____________________________________________.
(Name of Affiant)
____________________________________
NOTARY PUBLIC OR DEPUTY CLERK
{SEAL}
____________________________________
{Print, type, or stamp commissioned name
of notary or clerk.}
_____ Personally known
_____ Produced identification
Type of identification produced: ______________________________________
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IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 10 February 2021

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