Fillable INSTRUCTIONS FOR FILING AN AFFIDAVIT OF VIOLATION OF (Pinellas County Clerk of the Circuit Court and Comptroller)

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INSTRUCTIONS FOR FILING AN AFFIDAVIT OF VIOLATION OF (Pinellas County Clerk of the Circuit Court and Comptroller)

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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:
• 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 threat, word,
or act to do violence to the vulnerable adult;
• Telephoning, contacting, or otherwise communicating with the vulnerable adult directly 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?
This form may be filed by the petitioner who obtained an injunction for protection against exploitation of
a vulnerable adult.
IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT
IN AND FOR _COUNTY, FLORIDA
_,
Petitioner
On behalf of:
____________________________,
Vulnerable Adult
v. Case No.:
Division:
_,
Respondent
/
AFFIDAVIT OF VIOLATION OF INJUNCTION
AGAINST EXPLOITATION OF A VULNERABLE ADULT
STATE OF FLORIDA
COUNTY OF PINELLAS
I, , swear and affirm that the following facts are true
and correct:
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 threat,
word, or act to do violence to the vulnerable adult;
Telephoning, contacting, or otherwise communicating with the vulnerable adult directly
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.
The following lines may be used to briefly explain any alleged violation:
AFFIANT HEREBY CERTIFIES UNDER PENALTY OF PERJURY THAT THE STATEMENTS AND FACTS IN THIS
AFFIDAVIT ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Dated:
Signature of Party
Printed Name:
Address:
City, State, Zip: ________
Telephone Number:
Fax Number:
Designated E-mail Address(es):
STATE OF FLORIDA
COUNTY OF
Sworn to or affirmed and signed before me on , 20 , by .
NOTARY PUBLIC or DEPUTY CLERK
Printed Name:
Personally known
Produced identification:
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INSTRUCTIONS FOR FILING AN AFFIDAVIT OF VIOLATION OF (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 10 February 2021

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