SHERIFF’S OFC DOMESTIC/REPEAT - DATING/SEXUAL VIOLENCE WORKSHEET CASE NO. ____________________ General Information 1. How are you related to the Respondent: _________________________________________ 2. If you are married to the Respondent, what is the date of your marriage:________________ 3. Have you suffered physical domestic or repeat violence from the Respondent:___________ 4. Was a law enforcement officer called as a result of Dom/Rep/Date violence:___________________ 5. If Yes, was a report written:_____________ When was it filed:_______________________ 6. Was an arrest made:__________ If yes, when was the Respondent arrested: ____________ 7. Give names & ages of any minor children between you and the Respondent: ________________________________(____) ____________________________(_____) ________________________________(____) ____________________________(_____) 8. IMPORTANT: Who is in physical possession of the minor child(ren) at this time: Please check one: Petitioner ___________, Respondent: __________, Other: ______________. Petitioner Information Cell Ph# ____________________________ 1. Name: ________________________________ Phone # ____________________________ 2. Home Address: _____________________________________________________________ 3. Place of Emp & Add: ________________________________________________________ 4. Date of birth: ____________________ Race: _____________ Gender: ________________ Hgt: __________ Wgt: __________ Eye Color: __________ Hair Color: ______________ Respondent Information Cell Ph# _____________________ 1. Name: ______________________________________ Phone# ______________________ 2. Home Address: _____________________________________________________________ 3. Place of Emp & Add: ________________________________________________________ 4. Work days & hours: ____________________________ Wk Phone # __________________ 5. Date of birth (or approx age): __________________ Race: _________ Gender: ________ 6. Height: __________ Weight: ___________ Eye color: _________ Hair: ______________ 7. Scars or tattoos: ____________________________________________________________ 8. Other address where Respondent may be found:___________________________________ __________________________________________________________________________ 9. Does the Respondent own any weapons? ______ If yes, what type?___________________ 10. Description of Respondent’s vehicle: ____________________________________________ 03/15/2011 American LegalNet, Inc. www.FormsWorkFlow.com