SUPERIOR COURT OF THE DISTRICT OF COLUMBIA DOMESTIC VIOLENCE UNIT CIVIL PROTECTION INFORMATION SHEET PLEASE PRINT CASE # IF DATE OTHER CASE # CIVIL CRIMINAL PETITIONER'S INFORMATION IF YOUR ADDRESS IS CONFIDENTIAL FROM THE RESPONDENT, PLEASE GIVE A SAFE ADDRESS WHERE THE COURT CAN REACH YOU. 1. NAME 2. ADDRESS 3. HOME TELPHONE NO. WORK TELEPHONE NO. 4. DATE OF BIRTH RACE SEX HGT. PLEASE CHECK ONE NO YES ARE YOU COMING FROM ROOM 4235 THE DOMESTIC VIOLENCE INTAKE OFFICE? HAVE YOU BEEN TO THE DOMESTIC VIOLENCE INTAKE OFFICE IN THE LAST MONTH? WERE THE POLICE CALLED TO THE SCENE OF THE INCIDENT? DID THE POLICE ARREST THE RESPONDENT IN THIS CASE? DID YOU MEET WITH A REPRESENTATIVE FROM THE UNITES STATES ATTORNEY'S OFFICE TODAY? IS THE RESPONDENT IN LOCK UP TODAY? RESPONDENT'S INFORMATION 1. NAME 2. ADDRESS 3. HOME TELEPHONE NO. 4. DATE OF BIRTH WEIGHT WORK TELEPHONE NO. RACE EYECOLOR SEX HGT. HAIRCOLOR 5. PLACE OF EMPLOYMENT & ADDRESS American LegalNet, Inc. www.USCourtForms.com