Case Identification Information For Confidential Form For Foreign Protection Order {PO-0120}

CASE IDENTIFICATION INFORMATION FOR CONFIDENTIAL FORM FOR FOREIGN PROTECTION ORDER For use by Court, Clerk, Prosecuting Attorney, and Law Enforcement Personnel ONLY DIVISION OF STATE COURT ADMINISTRATION STATE OF INDIANA ) COURT: (check one) Superior, Room #: _________ Circuit COUNTY OF _________ ) _______________________________________________ PETITIONER/PLAINTIFF/STATE OF INDIANA CASE #: _________-________-_____-_________ DATE: ________________ m/d/yyyy v. _______________________________________________ RESPONDENT/DEFENDANT _______________________________________________ EMPLOYEE (IF WVRO) PERSON RESTRAINED Name: Home address: Home: Work: Cell: Email: (______)_____________________ (______)_____________________ (______)_____________________ __________________________________________ Postal address (if different from home address): Location of place of business or where person is usually or often found: Sex: DOB: male female Describe nature and location of any scars or tattoos: Yes Hair color: No Eye Color: Height: Weight: Any scars or tattoos? Race: List the name(s), age, race, and sex of any person(s) residing at the household of the protected person. Attach additional sheet of paper if necessary. Name: Age: Race: Age: Race: Age: Race: Age: Race: Age: Race: Sex: Male Female Name: Sex: Male Female Name: Sex: Male Female Sex: Male Female Name: Name: Sex: Male Female 1 TCM-PO-0120 Approved 07/02 Rev. by State Ct. Admin. 07/14 American LegalNet, Inc. www.FormsWorkFlow.com SECTION I. TERMS AND CONDITIONS OF FOREIGN PROTECTION ORDER [check all that apply] 01 The Respondent/Defendant is restrained from assaulting, threatening, abusing, harassing, following, interfering with, or stalking the Petitioner/Protected Person and/or the child of the Petitioner/Protected Person. 02 The Respondent/Defendant shall not threaten a member of the Petitioner/Protected Person's family or household. 03 The Petitioner/Protected Person is granted exclusive possession of the residence or household. 04 The Respondent/Defendant is required to stay away from the residence, property, school or place of employment of the Petitioner/Protected Person or other family or household member. 05 The Respondent/Defendant is restrained from making any communication or contact with the Petitioner/Protected Person(s), including but not limited to, personal, written, or telephone contact, or their employer, employees, or fellow workers, or others with whom the communication would be likely to cause annoyance or alarm to the Petitioner/Protected Person(s). 06 The Respondent/Defendant [not the Petitioner/Protected Person] is awarded temporary custody of the children named. 07 The Respondent/Defendant is prohibited from possessing and/or purchasing a firearm or other weapon or ammunition. 08 Special terms and conditions of the Foreign Protection Order. Please comment: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 09 The Petitioner is awarded custody of the named children. 10 The Respondent is prohibited from having any communication or contact with the named children, including but not limited to, personal, written, or telephone contact. 2 TCM-PO-0120 Approved 07/02 Rev. by State Ct. Admin. 07/14 American LegalNet, Inc. www.FormsWorkFlow.com SECTION II. FOR USE BY CLERK OF COURT A copy of this Confidential Data Entry Form for Foreign Protection Orders has been sent to the following law enforcement agencies: _______ Sheriff of ______________________________________________ County. _______ Any other sheriff or enforcement agency of a municipality listed in this Form: Name(s) of county(ies):_____________________________________________________________. Name(s) of municipality(ies):________________________________________________________. The copy was transmitted on (date):______________________________ by (name of person transmitting copy):_____________________________________. NOTE: This portion must be completed when a protection, no-contact, workplace violence restraining order is requested. The information provided on this form will be used to update the statewide protective order database for the enforcement of the order. CONFIDENTIAL FORM FOR FOREIGN PROTECTION ORDER NOTE: The following information is confidential under Indiana law pursuant to Indiana Code § 5-2-7, and it may not be released. PETITIONER Home address: DOB: Race: Sex: SSN: (optional) male female Home: Work: Cell: Email: (______)_____________________ (______)_____________________ (______)_____________________ __________________________________________ Postal address (if different from home address): When can protected person be reached at the above numbers or any alternative numbers? List the cities/counties where the protected person would like a copy of the order sent: ____________________________________________________ ____________________________________________________ _________________________________________________ Other protected address: Address from confidentiality program of Attorney General: PERSON RESTRAINED SSN: ___________________________________ End of Confidential Form. The "Confidential Form" portion of this form must be on green paper according to Admin. Rule 9 3 TCM-PO-0120 Approved 07/02 Rev. by State Ct. Admin. 07/14 American LegalNet, Inc. www.FormsWorkFlow.com