FORM 10-A: PROTECTION ORDER NOTICE TO NCIC Case/Order No. _______________________________ Page 1 of 2 PROTECTION ORDER NOTICE TO NCIC (Required fields appear in bold print) Initial NCIC Form Modification of Previous Form Pursuant to Rules 10.01, 10.02, 10.03, and 10.05 of the Rules of Superintendence for the Courts of Ohio, this information shall be promptly entered into the National Crime Information Center index. SUBJECT NAME (LAST) ADDRESS (STREET) PHYSICAL DESCRIPTION: HGT EYES 1. 3.* SSN DRIVER'S LIC. NO. STATE WGT RACE 2. DOB (CITY) HAIR SEX / EXPIRATION YR. EXPIRATION YR. M F / (STATE) (ZIP) (FIRST) (M.I.) NUMERICAL IDENTIFIER (NOTE: Only ONE of the 4 numerical identifiers is needed.) 4.* VEHICLE LIC. NO. STATE (* If #3 or #4 is used as a numerical identifier, entire line MUST be completed.) 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 the Order protect an intimate partner or child(ren)? Did the subject have an opportunity to participate in the hearing regarding the Order? Does the Order find the subject a credible threat or explicitly prohibit physical force? CASE / ORDER NO. COURT ORIGINATING AGENCY IDENTIFIER R.C. 2903.213 DATE OF ORDER R.C. 2903.214 / / R.C. 2151.34 NAME OF JUDGE/MAGISTRATE EXPIRATION OF ORDER / / (IN R.C. 2919.26 AND 2903.213 CASES, "NONEXP" MAY BE USED) R.C. 2919.26 YES YES YES NO NO NO (15 DIGIT MAXIMUM) (9 DIGIT ORI ASSIGNED BY NCIC) R.C. 3113.31 TERMS AND CONDITIONS OF ORDER (Mark all that are applicable): 01 02 03 04 OHP DATA 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. The subject shall not threaten a member of the protected person's family or household. The protected person is granted exclusive possession of the residence or household. 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. 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. 05 ONLY #EPO 06 07 08 The subject has visitation or custody rights of the children named in this Order. The subject is prohibited from possessing and/or purchasing a firearm or other weapon as identified in the Miscellaneous Field. See the Miscellaneous Field for comments regarding the specific terms and conditions of this Order. Miscellaneous comments: 09 The protected person is awarded temporary exclusive custody of the children named. FORM 10-A: PROTECTION NOTICE TO NCIC Amended: March 1, 2014 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com [Page 2 of 2 of Form 10-A] Subject's Name____________________________ Case/Order No. __________________________ LIST ALL PROTECTED PERSONS (Total of 9 allowed. SSN is NOT necessary if DOB is given.) PROTECTED PERSON (LAST) DOB SEX M F / / SSN (FIRST) RACE (M.I.) PROTECTED PERSON (LAST) DOB SEX M F / / SSN (FIRST) RACE (M.I.) PROTECTED PERSON (LAST) DOB SEX M F / / SSN (FIRST) RACE (M.I.) PROTECTED PERSON (LAST) DOB SEX M F / / SSN (FIRST) RACE (M.I.) PROTECTED PERSON (LAST) DOB SEX M F / / SSN (FIRST) RACE (M.I.) PROTECTED PERSON (LAST) DOB SEX M F / / SSN (FIRST) RACE (M.I.) PROTECTED PERSON (LAST) DOB SEX M F / / SSN (FIRST) RACE (M.I.) PROTECTED PERSON (LAST) DOB SEX M F / / SSN (FIRST) RACE (M.I.) PROTECTED PERSON (LAST) DOB SEX M F Date Judge/Magistrate (circle one) i (FIRST) SSN RACE (M.I.) / / Authorized by (signature): / / FORM 10-A: PROTECTION NOTICE TO NCIC Amended: March 1, 2014 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com