FORM 10-A: PROTECTION ORDER NOTICE TO NCIC Initial NCIC Form Modification of Previous Form (Required fields appear in bold print) of Pages SUBJECT NAME (LAST) (FIRST) (M.I.) ADDRESS (STREET) PHYSICAL DESCRIPTION: (CITY) HGT WGT HAIR (STATE) EYES (ZIP) SEX RACE NUMERICAL IDENTIFIER (NOTE: Only ONE of the 4 numerical identifiers is needed.) 1. SSN / / 2. DOB / 3.* DRIVER’S LIC. NO. STATE EXPIRATION YR. 4.* VEHICLE LIC. NO. STATE EXPIRATION YR. (* If #3 or #4 is used as a numerical identifier, entire line MUST be completed.) / LIC. TYPE BRADY DISQUALIFIERS: (Pursuant to 18 U.S.C. 922(g)(8), a “yes” response to all three Brady questions disqualifies the subject from purchasing or possessing any firearms, including a rifle, pistol, revolver, or ammunition.) Does Order protect an intimate partner or child(ren)? YES NO Did subject have opportunity to participate in hearing regarding Order? YES NO Does Order find subject a credible threat or explicitly prohibit physical force? YES NO CASE / ORDER NO. (15 DIGIT MAXIMUM) COURT ORIGINATING AGENCY IDENTIFIER R.C. 2903.213 R.C. 2919.26 R.C. 2903.214 R.C. 3113.31 (9 DIGIT ORI ASSIGNED BY NCIC) R.C. 2151.34 DATE OF ORDER ______ / ______ / ______ NAME OF JUDGE EXPIRATION OF ORDER ______ / ______ / ______ (IN R.C. 2919.26 CASES, “NONEXP” MAY BE USED) TERMS AND CONDITIONS OF ORDER (Mark all that are applicable): 01 The subject is restrained from assaulting, threatening, abusing, harassing, following, interfering, or stalking the protected person and/or the child(ren) of the protected person. 02 The subject shall not threaten a member of the protected person’s family or household. 03 The protected person is granted exclusive possession of the residence or household. 04 The subject is required to stay away from the residence, property, school, or place of employment of the protected person or other family or household member. 05 The subject is restrained from making any communication with the protected person, 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 the victim. 06 The subject has visitation or custody rights of the children named in this Order. 07 The subject is prohibited from possessing and/or purchasing a firearm or other weapon. 08 See the Miscellaneous Field for comments regarding the specific terms and conditions of this Order. Miscellaneous comments: OHP DATA ONLY LIST ALL PROTECTED PERSONS (Total of 9 allowed, may attach additional forms; SSN is NOT necessary if DOB is given): #EPO PROTECTED PERSON 09 The protected person is awarded temporary exclusive custody of the children named. (LAST) DOB / / (FIRST) SSN / SSN / SSN / / (M.I.) RACE SEX RACE SEX RACE SEX PROTECTED PERSON (LAST) DOB MIS/ / / (FIRST) / (M.I.) PROTECTED PERSON (LAST) DOB / / (FIRST) Authorized by (signature): / (M.I.) Date Judge/Magistrate (circle one) FORM 10-A: PROTECTION NOTICE TO NCIC Amended: July 1, 2010 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com