STATE OF INDIANA ) ) SS: COUNTY OF ___________ ) IN THE ________________COURT _____ (_____________ DIVISION, ROOM ____) CASE NO.__________________________ _______________________, Petitioner/Protected Person (Your Name) vs. _______________________, Respondent/Defendant ) ) ) ) ) REGISTRATION OF FOREIGN PROTECTION ORDER FORM Indiana Code § 34-26-5-17 (e) Note to Petitioner/Protected Person: If you are registering your Foreign Protection Order with the Court for the first time, you must complete Section A. If you are notifying the Court of an extension, modification, or termination of the Foreign Protection Order, complete Section B. Section A--First Registration of Foreign Protection Order 1. 2. 3. 4. 5. 6. I, ______________________________________, am the Petitioner/Protected Person named in the attached Foreign Protection Order. The issuing State or Tribe for the attached Foreign Protection Order is: __________________________________________. The Order was issued by the _____________________ Court of that State or Tribe. The Order was issued on the date of: __________________________. The Order will expire on the date of: __________________________. The address and telephone number of the Court that issued the Order are: __________________________________________________________ __________________________________________________________. Is this an ex parte Order? Yes ___ No ___ Is the attached copy of the Foreign Protection Order a certified copy? Yes ___ No ___ Does the Order prohibit the respondent/defendant from possessing a firearm, ammunition, or deadly weapon? Yes ___ No ___ Place an "X" next to the type of case this Order was issued in: a. Criminal case ___ (if yes, please describe what charge(s) is/are involved) ____________________________________________________. b. Juvenile case ___ (if yes, please describe the nature of the case [delinquency, child abuse/neglect, etc.]) _____________________ _____________________________________________________. c. Paternity/Child Support case ___ d. Custody/Parenting time case ___ e. Divorce/Legal Separation/Dissolution of Marriage case ___ 7. 8. 9. 10. 1 TCM-PO-0119 Approved 07/02 Rev. by State Ct. Admin. 07/14 American LegalNet, Inc. www.FormsWorkFlow.com f. g. Civil Protective Order case ___ Other type of case (please describe) ________________________ _____________________________________________________. 11. The Order awards ___Petitioner ____Respondent custody of the parties' minor children: ___Yes ___No If yes, provide name, age, and date of birth of each child: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ The Order prohibits Respondent from having any communications or contact with the named child(ren). ___Yes ___No Describe the custody provisions and/or conditions of the Order: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ The Order ___grants ___does not grant parenting time/visitation to the ____Petitioner ______Respondent. Terms of parenting time/visitation: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ I understand that it is my responsibility to notify the Clerk of this Court if the attached Foreign Protection Order is extended, modified, or terminated. (Place your initials here to indicate you have read this statement and understand it: _____) I understand that if the attached Foreign Protection Order is extended, modified, or terminated, or if I have a change of address or other change of circumstances, I must return to this office and complete a new Confidential Data Entry Form for Foreign Protection Orders in order to keep my information current. If the Order is extended or modified, I must bring a copy of the extended or modified Order with me. (Place your initials here to indicate you have read this statement and understand it: _____) I have completed a Confidential Data Entry Form for Foreign Protection Orders. 12. 13. 14. 15. 16. 17. Section B--Extension, Modification, or Termination of Foreign Protection Order 1. I, ______________________________________, am the Petitioner/Protected Person named in the attached Foreign Protection Order. 2 TCM-PO-0119 Approved 07/02 Rev. by State Ct. Admin. 07/14 American LegalNet, Inc. www.FormsWorkFlow.com 2. 3. 4. 5. 6. 7. 8. 9. (If applicable) I am notifying the Court that the Order expired on the date of: ________________________; or, I am notifying the Court that the Order was vacated or dismissed on the date of: ______________________________. (If applicable) I am notifying the Court that the Order was modified on the date of: ________________________ as follows: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________. (If applicable) I am notifying the Court that the Order has been extended, and will remain in effect until the date of: ______________________________________. If the Order was extended or modified, was the Respondent given notice? Yes ___ No ___ Is the attached copy of the Foreign Protection Order a certified copy? Yes ___ No ___ I understand it is my responsibility to notify the Clerk of this Court if the attached Foreign Protection Order is further extended, modified, or terminated (if applicable). (Place your initials here to indicate you have read this statement and understand it: _____) I understand that if the attached Foreign Protection Order is extended, modified, or terminated (if applicable), or if I have a change of address or other change of circumstances, I must return to this office and complete a new Confidential Data Entry Form for Foreign Protection Orders in order to keep my information current. (Place your initials here to indicate you have read this statement and understand it: _____) I have completed a Confidential Data Entry Form for Foreign Protection Orders. I affirm, under the penalties for perjury, that the foregoing representations are true, and that the attached For