STATE OF WISCONSIN

[COUNTY] COUNTY CIRCUIT COURT – FAMILY DIVISION

Case No. [______]

DOMESTIC ABUSE INJUNCTION AND PROTECTION ORDER
(pursuant to Wis. Stat. § 813.12)

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
   3.1 Prohibited Conduct
   3.2 Stay-Away & No-Contact Radius
   3.3 Firearms & Dangerous Weapons Surrender
   3.4 Law-Enforcement Assistance
   3.5 Child-Related Relief (Optional)
   3.6 Financial Support (Optional)
   3.7 Duration & Expiration
4. Findings (Representations & Warranties)
5. Enforcement, Violation & Penalties
6. Modification, Extension & Termination
7. General Provisions
8. Execution & Service Block

1. DOCUMENT HEADER

This matter came before the Court on [HEARING DATE] on the verified petition of [PETITIONER LEGAL NAME] (“Petitioner” or “Protected Party”) against [RESPONDENT LEGAL NAME] (“Respondent”).
Having reviewed the pleadings, heard testimony, and being fully advised, the Court ORDERS as follows, effective [EFFECTIVE DATE] and subject to the terms herein.

[// GUIDANCE: Insert “Temporary Order” if issued ex parte and replace references to “injunction” with “temporary restraining order” throughout.]

2. DEFINITIONS

For purposes of this Order, capitalized terms carry the meanings set forth below:

“Abuse” – Conduct defined in Wis. Stat. § 813.12(1) including intentional physical harm, sexual assault, stalking, destruction of property, threats, or any act that places Petitioner in fear of imminent harm.

“Child/Minor Child” – Any individual under the age of 18 who is the natural, adopted, or step-child of either party and specifically identified in Exhibit A.

“Firearm” – Any weapon that expels a projectile by action of an explosive; includes ammunition.

“Prohibited Contact” – Direct or indirect contact of any kind, including but not limited to in-person contact, telephone calls, text messages, e-mails, social media interactions, third-party communications, gifts, and surveillance.

“Protected Address(es)” – The residential, school, childcare, or employment locations listed in Exhibit B or subsequently designated in writing by Petitioner.

“Stay-Away Radius” – A distance of [___] feet/yards/miles from any Protected Address.

3. OPERATIVE PROVISIONS

3.1 Prohibited Conduct

a. Respondent shall not commit or threaten to commit Abuse against Petitioner or any Child.
b. Respondent shall refrain from all Prohibited Contact with Petitioner and the Child(ren).

3.2 Stay-Away & No-Contact Radius

a. Respondent shall remain outside the Stay-Away Radius of any Protected Address.
b. Incidental contact in public places within the Stay-Away Radius must be avoided; if unavoidable, Respondent shall immediately depart.

3.3 Firearms & Dangerous Weapons Surrender

a. Pursuant to Wis. Stat. § 813.12(4m), Respondent shall, within 48 hours of service of this Order, surrender all Firearms and dangerous weapons in Respondent’s possession to the sheriff of [COUNTY] County or a federally-licensed firearms dealer and file proof of surrender (Form CV-434) with the Clerk.
b. Respondent is prohibited from acquiring or possessing Firearms while this Order remains in effect.

3.4 Law-Enforcement Assistance

a. Petitioner may request, and any Wisconsin law-enforcement agency shall provide, stand-by assistance to secure Petitioner’s personal effects, residence, or child custody transfers.
b. Officers are authorized to arrest Respondent without warrant for any violation of this Order per Wis. Stat. § 813.12(7).

3.5 Child-Related Relief (Optional)

a. Temporary Custody. Sole legal and physical custody of the Child(ren) is awarded to Petitioner.
b. Visitation/Supervised Placement. Any visitation shall be [supervised/unrestricted/denied] in accordance with Schedule C; exchanges shall occur at [location] in the presence of [supervisor or agency].
c. School & Medical Decisions. Petitioner shall exercise sole decision-making authority.

[// GUIDANCE: Insert only if children are involved; delete bracketed terms otherwise.]

3.6 Financial Support (Optional)

Respondent shall pay temporary family support in the amount of $[___] per [week/month], commencing [date], through the Wisconsin Support Collections Trust Fund, until further order.

3.7 Duration & Expiration

This injunction shall remain in effect until [EXPIRATION DATE] (not to exceed four (4) years unless the Court specifically finds, under § 813.12(4)(c)-(d), justified extension up to ten (10) years).
The Order is enforceable upon signature and remains valid even if Respondent is absent or not served until modified or vacated by the Court.

4. FINDINGS (REPRESENTATIONS & WARRANTIES)

The Court expressly finds:

1. Jurisdiction & Venue. This Court has subject-matter jurisdiction under Wis. Stat. § 813.12 and personal jurisdiction over the parties.
2. Relationship. The parties are/were [spouses/former spouses/parent of a common child/cohabiting/dating], satisfying Wis. Stat. § 813.12(1)(a).
3. Domestic Abuse Occurred. Respondent has engaged in Abuse as defined by statute.
4. Immediate Danger. Without the relief herein, Petitioner is at risk of continued Abuse.
5. Least-Restrictive Means. The restraints imposed are narrowly tailored to protect Petitioner while respecting Respondent’s rights.

5. ENFORCEMENT, VIOLATION & PENALTIES

1. Criminal Penalties. Violation of this Order constitutes a Class A misdemeanor under Wis. Stat. § 813.12(8) punishable by up to 9 months incarceration and/or a fine of up to $10,000.
2. Civil Contempt. The Court may impose fines, imprisonment, or other sanctions for contempt.
3. Full Faith & Credit. This Order is enforceable in all 50 states, D.C., tribal lands, and U.S. territories pursuant to 18 U.S.C. § 2265.
4. Notice to Respondent. Receipt of certified copy, personal service, or actual notice is sufficient for enforcement.

6. MODIFICATION, EXTENSION & TERMINATION

1. Modification. Either party may move, with notice to the other, to modify terms; relief shall be granted only upon a showing of good cause and continued necessity.
2. Extension. Petitioner may petition for an extension under Wis. Stat. § 813.12(4)(c) by filing at least 14 days before expiration; the Court may extend without further abuse upon showing of continued risk.
3. Early Termination. Upon joint stipulation or Petitioner’s written request and Court approval, the injunction may be vacated.

7. GENERAL PROVISIONS

1. Severability. If any provision is held invalid, the remainder shall remain in full force.
2. Governing Law. This Order is governed by Wisconsin law.
3. No Waiver. Failure to enforce any provision does not waive future enforcement.
4. Notice of Federal Restrictions. Respondent is advised that possession of firearms while subject to this Order may violate 18 U.S.C. § 922(g)(8).
5. Record Confidentiality. Petitioner’s addresses and identifying information shall remain confidential per Wis. Stat. § 813.12(5g).

8. EXECUTION & SERVICE BLOCK

Issued at [City], Wisconsin on [DATE].

[PRINTED NAME], Circuit Court Judge
Branch [___], [County] County Circuit Court

(Court Seal)

Respondent Acknowledgment of Receipt

I, [RESPONDENT NAME], hereby acknowledge receipt of a certified copy of this Order on [DATE/TIME].

Signature of Respondent

Certificate of Service

I certify that a true and correct copy of this Order was served upon Respondent by [method] on [DATE/TIME].

Name & Title of Serving Officer

EXHIBIT A – Minor Children Covered by this Order

[List full names, dates of birth]

EXHIBIT B – Protected Addresses

[Residence, school, employer, daycare, other critical locations]

EXHIBIT C – Visitation / Placement Schedule (if applicable)

[Detailed schedule]

[// GUIDANCE:
1. Always attach the Wisconsin Department of Justice “Notice to Domestic Abuse Victims” form to provide statutory advisements.
2. Confirm compliance with mandatory firearms-surrender protocol and filing of CV-435 “Firearms Possession Notification.”
3. For ex parte issuance, schedule a full injunction hearing within 14 days under § 813.12(3)(c).
4. Verify confidentiality boxes on CCAP filings to protect Petitioner’s address.
5. Adapt “Child-Related Relief” to avoid conflicting with existing family-law orders; coordinate with the judge if there is a pending divorce or paternity matter.
]