Respondent Information Form As Provided By Petitioner

RESPONDENT INFORMATION FORM AS PROVIDED BY PETITIONER G.L. c. 123 § 35 DOCKET NO. (for court use only) Trial Court of Massachusetts This information is requested to help police identify and locate the Respondent in order to serve the Respondent with any summons or execute any warrant of apprehension pursuant to G.L. c. 123 § 35. Please provide as much information as possible. RESPONDENT'S NAME OTHER NAMES USED BY RESPONDENT, IF ANY RESPONDENT'S DATE OF BIRTH RESPONDENT'S PLACE OF BIRTH RESPONDENT'S SOCIAL SECURITY NUMBER MOTHER'S MAIDEN NAME (FIRST, LAST) FATHER'S NAME (FIRST, LAST) SEX MALE FEMALE RACE EYE COLOR HAIR COLOR HEIGHT WEIGHT BUILD PHOTO AVAILABLE (HELPFUL FOR ID) PLEASE ATTACH YES NO OTHER PHYSICAL CHARACTERISTICS (beard, glasses, scars, tattoos, complexion, hairstyle) RESPONDENT'S HOME ADDRESS (NO,, STREET, CITY, STATE, ZIP CODE) APT NO. FLOOR NO. NAME ON DOOR/MAILBOX RESPONDENT'S HOME PHONE NO. RESPONDENT'S CELL PHONE NO. DOES THE RESPONDENT UNDERSTAND ENGLISH? YES NO IF NOT, WHAT LANGUAGES? RESPONDENT'S EMPLOYER/WORKPLACE TITLE DEPARTMENT WORK ADDRESS (NO., STREET, CITY, STATE, ZIP CODE) WORK TELEPHONE NO. WORK HOURS OTHER PLACES RESPONDENT MAY BE FOUND (friends, bars, relatives, hangouts) BEST PLACE TO FIND RESPONDENT BEST TIME TO FIND RESPONDENT MOTOR VEHICLE LICENSE PLATE YEAR MAKE MODEL COLOR DOES THE RESPONDENT HAVE: (describe briefly) A history of violence toward police officers? A history of using/abusing drugs or alcohol? If so, what kind? Access to guns, a license to carry, or possess a gun? If so, what kind? Psychiatric/emotional problems? If so, what kind? YES YES YES YES NO NO NO NO Any other information which might be helpful in locating the Respondent: DATE SIGNED PETITIONER'S NAME (printed) PETITIONER'S SIGNATURE (Rev. 4/16) www.FormsWorkFlow.com