Notice Of Extension Or Modification {PO-0117}

PO-0117 Approved 07-01-02 Revised 07-23-04 NOTICE OF EXTENSION OR MODIFICATION DIVISION OF STATE COURT ADMINISTRATION STATE OF INDIANA ) COUNTY OF ____________) COURT: Supe rior, Room #: _________ (check one) Circuit _____________________________________ CASE #:__________________________________ PETITIO NER/PLAINTIFF/STATE OF INDIANA V. _____________________________________ DATE: __________________________ RESP ONDENT/DEFENDANT _______________________________________________ EMPLOYEE (IF WVRO ) Notice is hereby given that an order previously issued under the provisions of IC 5-2-9has been extended or modified . PERSON PROTECTED Name: ______________________________________________________________________ Date of birth:_______________________ Race: ___________________________Sex: Male [ ] Female [ ] PERSON RESTRAINED Name: ______________________________ Telephone No.: Home:( )______________________ Date of birth:____________________ Work: ( )______________________ Sex: Male [ ] Female [ ] Race:_______________________________ Home Address:____________________________________________________________________ _______ Location of place of business or where person usually/often found:__________________________________ Social Security Number (if known):_______________________________________________ REASON FOR EXTEN SION OR MODIFICATION _____(a.) Extended due to: _______ motion for continuance. Hearing date moved to:_____________(date). Conditions of the order remain unchanged. _______ renewal of existing order; termination date changed to:____________(date). See attached order. Conditions of the order remain unchanged. ______(b.) Modified due to: _________Petitioners/Protected s or Respondents/Defendants Person change of address (NOTE: page 3 of this form needs to be comONLY WHEN pleted this applies). _________ conditions of the order have been modified. See attached order. _________other. See attached order. Date order was issued:__________________________________________________ ________ Date order was modified or extended:____________________________________________________ _____ Date order will be terminated:_______________________________________________________________ 1 <<<<<<<<<********>>>>>>>>>>>>> 2PO-0117 Approved 07-01-02 Revised 07-23-04 TYPE OF ACTION _____ No Contact Order Juvenile Court [IC 31-32-13] _____ No Contact Order CHINS [ IC 31-34-20] _____ No Contact Order CHINS [IC 31-34-25] _____ No Contact Order Delinquency [IC 31-37-19] _____ No Contact Order Delinquency [IC 31-37-25] _____ No Contact Order Pretrial Diversion [IC 33-14-1-7] _____ Ex Parte Order for Protection [IC 34-26-5] _____ Order for Protection Issued After a Hearing [IC 34-26-5] _____ Workplace Violence Restraining OrderTRO [IC 34-26-6] _____ Workplace Violence Restrainng Orderi Injunction [IC 34-26-6] _____ No Contact Order Pretrial Release [IC 35-33-8-3.2 ] _____ No Contact Order Condition of Probation [IC 35-38-2-2.3] Prepared by:____________________________________________________________ __ Notice to Protected Person/Plaintiff: The address and telephone number listed here will not be kept confidentialThe Protected Person/Plaintiff . should designate a Public Mailing Address for purposes of serving pleadings, notices, and court orders. Name: ____________________________________________________________________ ____________ Address:________________________________________________________________ ________________ __________________________________________________________ ______________________ City: ____________________________________________________________ _____ Telephone:____________________________________ Attorney Number (if applicable): __________________ FOR USE BY CLERK OF COURT NOTICE OF EXTENSION OR MODIFICATION has been sent to the following Depositories: _______ Sheriff of ______________________________________________ County . _______ Any other sheriff or enforcement agency of a municipality named in the order: Name(s) of county(ies):_________________________________________________ ____________. Name(s) of municipality(ies):________________________________________________________. 2 <<<<<<<<<********>>>>>>>>>>>>> 3PO-0117 Approved 07-01-02 Revised 07-23-04 CONFIDENTIAL PAGE COMPLETE THIS PAGE FOR CHANGE OF ADDRESS FOR USE BY COURT, CLERK, PROSECUT ING ATTORNEY, AND LAW ENFORCEMENT PERSONNEL ONLY Note: The following informndiana law pursuant to IC 5-2-9ation is confidential under I-7, and it may not be released. ___________________________________ Petitioner/Plaintiff/State of Indiana vs. Case Number: ___________________________ ___________________________________ Respondent/Defendant ___________________________________ Date: ________________________________ Employee (If WVRO) Name of protected person:___________________________________________________ _______________ Date of birth: ____________________ Sex: Male [ Address:______________________________ Alternate address:____________ ______________________ _____________________________________ _______________________________ __________________ _____________________________________ _______________________________ __________________ Telephone Number:_____________________ Alternate Tel. #:_______________________ Within a municipal boundary? Yes ( ) No ( ) W ithin a mnicipal boundary?u Yes ( ) No ( ) Which municipality?____________________ Which municipality? ________________________ _____________________________________ _____________________________ _____________ Social Security Number (optional):________________________ Name of restrained person:__________________________________________________ ___________ Address:________________________________________________________________ ____________ Telephone Number:___________________________________________________________________ Date of birth:________________ Social Security Number (if known):___________________________ Sex: Male ( ) Female ( ) Race:______________________________ 3