‘ ORIGINAL ‘ MODIFICATION COMPLETE AND TAKE TO THE COURT WITH YOUR REQUEST FOR TEMPORARY RESTRAINING ORDERS LAW ENFORCEMENT INFORMATION FOR PROTECTIVE ORDERS This information will be entered into the Department of Justice’s restraining order system to prevent the defendant (restrained person) from purchasing or attempting to purchase a firearm for as long as the order is in effect. PERSON PROTECTED BY A ‘DOMESTIC VIOLENCE ‘ CIVIL HARASSMENT ‘ ELDER ABUSE or ‘ JUVENILE RESTRAINING ORDER (THE DEFENDANT IS NOT ALLOWED TO SEE THIS FORM) Print Only ________________________________________________________________________________________ Last Name First Name Middle Name Date of Birth ________________________________________________________________________________________ Street Address City State Zip Race -Choose from below PERSON TO BE RESTRAINED ________________________________________________________________________________ Last Name First Name Middle Name _______________________________________________________________________________________ Other Names used or Nicknames _______________________________________________________________________________________ SEX RACE _____Male _____Female ______________________________ DATE OF BIRTH: ______________________________ HEIGHT _____White _____Hispanic _____Japanese _____Filipino _____Guamanian _____Laotian _____Hawaiian _____Samoan _____Cambodian _____Black _____Chinese _____American Indian _____Pacific Islander _____Other Asian _____Vietnamese _____Korean _____Asian Indian _____Feet _____Inches ______________________________ WEIGHT _____Pounds _______________________________________________________________________________________ EYE COLOR (Check one only) HAIR COLOR (Check one only) _____Black _____Hazel _____Black _____Red _____Blue _____Maroon _____Blond _____Sandy _____Brown _____Pink _____Brown _____White _____Gray _____Multicolor _____Gray _____Bald _____Green ________________________________________________________________________________________ ADDRESS ________________________________________________________________________________________ Street Address City State Zip Code ________________________________________________________________________________________ Social Security Number___________________________________ Driver’s License Number____________________Driver’s License State____________________ Driver’s License Year of Expiration_____________________________ Sup Crt 182 (03/06) American LegalNet, Inc. www.FormsWorkflow.com