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IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL (Pasco County Clerk, FL)

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IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT
IN AND FOR PASCO COUNTY, FLORIDA
IN RE:
,
Alleged Vulnerable Adult,
,
Petitioner,
v. Case Number:
Section:
,
Respondent.
/
PETITION FOR INJUNCTION FOR PROTECTION
AGAINST EXPLOITATION OF A VULNERABLE ADULT
Before me, the undersigned authority, personally appeared the petitioner,
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:
Telephone 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:
Telephone 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:
2. The respondent’s last known place of employment is:
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:
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:
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.
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
financial institution}
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.
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
The foregoing instrument was acknowledged before me this ______ day of ________________,
20____ by ____________________________ personally known to me (or who has produced
_____________________ as identification) and who appeared to me
by physical presence
by means of audio-video communication technology and who
did did not take an oath.
_______________________________________
NOTARY PUBLIC – STATE OF FLORIDA
Name: __________________________________
Commission No.: _________________________
My Commission Expires: ____________________
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IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL (Pasco County Clerk, FL)

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Completed 23 June 2021

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