Free PETITION OF EMPLOYER FOR INJUNCTION PROHIBITING VIOLENCE OR THREATS OF VIOLENCE AGAINST EMPLOYEE - Indiana

WV-0101

Approved 07-01-02 Revised 07-01-03

STATE OF INDIANA

) )SS: COUNTY OF ____________)

IN THE __________________COURT___ (_______________DIVISION, ROOM___) CASE NO.__________________________

PLAINTIFF: ___________________________________________ DEFENDANT: _________________________________________ EMPLOYEE: __________________________________________ PETITION OF EMPLOYER FOR INJUNCTION PROHIBITING VIOLENCE OR THREATS OF VIOLENCE AGAINST EMPLOYEE __ Application for Temporary Restraining Order

Read the Instructions for Petitions to Prohibit Workplace Violence before completing this form. NOTE: Plaintiff must be an employer with standing to bring this action under IC 34-26-6-4. IMPORTANT: This is a public document and a copy of it will be placed in the Court's file. A copy may also be sent to the Defendant. 1. Plaintiff (name): _____________________________________ is a _ corporation __ sole proprietorship _ other (specify): ___________________________ and is filing this case on behalf of the employee identified in Paragraph 2. Employee (name): ___________________________________ Sex: __ Male __ Female Date of birth: _______________________________ (Use a separate petition for each employee you are seeking to protect.) Defendant (name): _______________________________________ a. Resides at (state address and county):___________________________ _________________________________________________________ b. Works at (state address and county): ___________________________ _________________________________________________________ c. __ Is __ Is not a current employee of plaintiff (explain if defendant is still an employee): _______________________ _________________________________________________________ _________________________________________________________ This case is filed in this county because a. __ defendant resides in this county. b. __ defendant has caused physical or emotional injury to plaintiff's employee in this county. c. __ other (specify): ______________________________________ ___________________________________________________ Page 1 of _____ pages

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WV-0101

Approved 07-01-02 Revised 07-01-03

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Defendant has __ battered __ stalked or __ made a credible threat of violence against the employee by knowing or willing statements or a course of conduct that would place a reasonable person in fear for his or her safety, or the safety of his or her immediate family. a. One of more of these acts can reasonably be construed to be carried out or to have been carried out at the employee's workplace at (address): ___________________________________________________________ ___________________________________________________________ b. Describe what happened (including the dates, who did what to whom, and any injuries): ________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ __ Continued on Attachment 5b. __ Employee will suffer great and irreparable harm before this petition can be heard in court unless the court makes those orders requested below effective now and until the hearing. (Specify the harm and why it will occur before the hearing): __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __ Continued on Attachment 6 __ Plaintiff/plaintiff's attorney hereby certifies the following (Check the appropriate box): __ Oral notice of this petition has been given to the defendant. __ Written notice of this petition has been given to the defendant. __ Oral notice of this petition has been given to the defendant's attorney. __ Written notice of this petition has been given to the defendant's attorney. __ A good faith attempt was made to inform the defendant and/or the defendant's attorney of this petition. The efforts to inform consisted of (specify): _________________________________________________ _________________________________________________________ __ Because of the following reasons, plaintiff/plaintiff's attorney should not be required to give notice to the defendant/defendant's attorney (specify): _________________________________________________ _________________________________________________________ _________________________________________________________ Defendant's conduct has been directed against employee and is knowing and willful, is not constitutionally protected, and does not constitute lawful acts of self-defense or defense of others.

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WV-0101

Approved 07-01-02 Revised 07-01-03

PLAINTIFF REQUESTS THE COURT TO MAKE THE ORDERS INDICATED BY THE CHECK MARKS IN THE BOXES BELOW. 8. __ RESTRAINING ORDERS __ To be ordered now and effective until the hearing a. Defendant shall not engage in unlawful violence or make threats of violence against the employee and the following members of employee's family or household who reside with the employee: (1) (Name): ____________________________________________ Sex: __ Male __ Female Date of birth: _______________________________ (2) (Name): ____________________________________________ Sex: __ Male __ Female Date of birth: __________________________________ (3) (Name): ____________________________________________ Sex: __ Male __ Female Date of birth: __________________________________ __ Continued on Attachment 8a. b. Specifically, defendant (1) __ shall not batter or stalk the employee and other protected persons. (2) __ shall not follow or stalk the employee and other protected persons to or from the place of work. (3) __ shall not follow the employee and other protected persons during hours of employment. (4) __ shall not telephone or send correspondence to the employee and other protected persons by any means including, but not limited to, the use of the public or private mails, interoffice mail, fax, or computer e-mail. (5) __ shall not enter the workplace of the employee and other protected persons. (6) __ other (specify): ________________________________________ ____________________________________________________ __ STAY-AWAY ORDERS __ To be ordered now and effective until the hearing. a. Defendant shall stay at least (specify): _____ yards away from the following places and persons (the addresses of the places are optional and may be kept confidential): (1) Employee __ and other protected person identified in Paragraph 8a. (2) __ Employee's residence (address optional): __________________ ______________________________________________________ (3) __ Employee's place of work (address optional): _______________ ______________________________________________________ (4) __ Employee's children's school or place of child care (address optional): ______________________________________________ ______________________________________________________ Page 3 of _____ pages

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WV-0101

Approved 07-01-02 Revised 07-01-03

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(5) __ Employee's vehicle (specify): ___________________________ _____________________________________________________ (6) __ Other (specify): ______________________________________ _____________________________________________________ Will granting of any of the stay-away orders in Paragraph 9a deprive Defendant of access to his or her residence or place of employment? __ Yes __ No (If yes, explain): ______________ _______________________________________________________ _______________________________________________________

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__ COSTS __ Defendant should be ordered to pay costs as follows (specify): __________ ______________________________________________________________ ______________________________________________________________ __ OTHER ORDERS (specify other orders you request to help carry out the orders previously requested): ______________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Plaintiff requests that copies of orders be given to the following law enforcement agencies: Law enforcement agency Address ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ __ Plaintiff requests that time for service of the Order to Show Cause and accompanying papers be shortened so that they may be served no less than (specify number): _____ days before the date set for the hearing. I need to have the order shortening time because of the facts contained in this petition. __ Plaintiff has asked for restraining orders against the defendant in (specify): ________________________ County, Case No. (specify): ________________ _______________________________________________________________ __ Employee has asked for an order for protection against the defendant in (specify): ____________________ County, Case No. (specify): ____________ _______________________________________________________________ DESCRIPTION OF DEFENDANT TO BE RESTRAINED Sex: __ Male __ Female Ht: _____ Wt. _____ Eye color: _______ Hair color: _________ Race: _________________ Page 4 of _____ pages

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WV-0101

Approved 07-01-02 Revised 07-01-03

Age: ______ 17. 18.

Date of birth: __________________

Plaintiff requests additional relief as may be proper. __ Plaintiff is not required to pay a fee for filing this petition because the petition alleges that the defendant has inflicted or threatened violence against an employee of the plaintiff, or stalked the employee, or acted or spoke in any other manner that has placed the employee in reasonable fear of violence, and seeks protective or restraining orders or injunctions restraining stalking or future violence or threats of violence in an action brought under IC 34-26-6-1 et seq. Plaintiff understands that if the court issues an Order to Show Cause, a hearing will be held on the date shown in Paragraph 2 of the Order to Show Cause. At that hearing, plaintiff will be prepared to present evidence supporting the petition. Number of pages attached: ______

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________________________________
(TYPE OR PRINT NAME)

______________________________
(SIGNATURE OF ATTORNEY, IF ANY)

I affirm, under the penalties for perjury, that the foregoing representations are true: a. on the basis of my own personal knowledge. b. on the basis that I have been informed and believe that the facts stated are true. (NOTE: If this petition is made solely on the basis of plaintiff's information and belief, plaintiff must attach affidavits by one or more persons who have personal knowledge of the facts stated.) Date: _________________________ _______________________________
(TYPE OR PRINT NAME)

______________________________
(SIGNATURE OF PLAINTIFF)

Title of person signing: __________________________________ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, attorney registration number, and address): TELEPHONE NO.: ATTORNEY FOR (Name): FAX NO.:

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