(a) A sworn petition filed under this section must allege the existence of exploitation, or the imminent exploitation, of the vulnerable adult and must include the specific facts and circumstances for which relief is sought. The sworn petition must be in substantially the following form: PETITION FOR INJUNCTION FOR PROTECTION AGAINST EXPLOITATION OF A VULNERABLE ADULT
Before me, the undersigned authority, personally appeared Petitioner (Name) , who has been sworn and says that the following statements are true:
1. The petitioner's name is:2. The petitioner's address is:3. The petitioner's relationship to the vulnerable adult is:4. How long has the petitioner known the vulnerable adult:5. The vulnerable adult's name is:6. Aliases of the vulnerable adult are:7. The vulnerable adult's date of birth is:8. The vulnerable adult's address is:9. Does the vulnerable adult have one or more impairments that impact his or her ability to perform normal activities of daily living or to provide for his or her own care or protection? Yes No
If so, what are this person's impairments? (check all that apply)
Long-term physical disability
Sensory disability (e.g., hearing or vision impaired)
Cognitive disability
Mental or emotional disability
Developmental disability
Infirmity of aging
Other (explain)
10. The respondent's last known address is:11. The respondent's last known place of employment is: (name of business and address) .12. Physical description of the respondent: Race
Sex
Date of birth
Height
Weight
Eye color
Hair color
Distinguishing marks or scars
13. Aliases of the respondent:14. The respondent is associated with the vulnerable adult as follows:15. The following describes any other cause of action currently pending between the petitioner and the respondent, any proceeding under chapter 744 concerning the vulnerable adult, and any previous or pending attempts by the petitioner to obtain an injunction for protection against exploitation of the vulnerable adult in this or any other circuit; related case numbers, if available; and the results of any such attempts:16. The following describes the petitioner's knowledge of any reports made to a 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 vulnerable adult; any investigations performed by a government agency relating to abuse, neglect, or exploitation of the vulnerable adult; and the results of any such reports or investigations:17. The petitioner knows the vulnerable adult is either a victim of exploitation or the petitioner has reasonable cause to believe the 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) 18. The following describes the petitioner's knowledge of the vulnerable adult's dependence on the respondent for care; alternative provisions for the vulnerable adult's care in the absence of the respondent, if necessary; available resources the vulnerable adult has to access such alternative provisions; and the vulnerable adult's willingness to use such alternative provisions:19. The petitioner knows the vulnerable adult maintains assets, accounts, or lines of credit at the following financial institution(s): (list name, address, and account number of each) .20. The petitioner believes that the vulnerable adult's assets to be frozen are: (mark one) . Worth less than $1500;
Worth between $1500 and $5000; or
Worth more than $5000.
21. The petitioner genuinely fears imminent exploitation of the vulnerable adult by the respondent.22. The petitioner seeks an injunction for the protection of the vulnerable adult, including: (mark appropriate section or sections) . Prohibiting the respondent from having any direct or indirect contact with the vulnerable adult.
Immediately restraining the respondent from committing any acts of exploitation against the vulnerable adult.
Freezing the assets of the 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 vulnerable adult at (name and address of financial institution) even if jointly with the respondent, in the court's discretion.
Providing any terms the court deems necessary for the protection of the vulnerable adult or his or her assets, including any injunctions or directives to law enforcement agencies.
23. Should the court enter an injunction freezing assets and credit lines, the petitioner believes that the critical expenses of the 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 payment is critical) .(b) Each petition for an injunction for protection against exploitation of a vulnerable adult must contain, directly above the signature line, a statement in all capital letters and bold type not smaller than the surrounding text, as follows: 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 SUCH 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.