Cover Sheet for Protection Order, No Contact Order, Child Protective Order, Workplace Violence Restraining Order COVER SHEET (Check Only One) Protection Order IC 34-26-5 Child Protective Order IC 31-34-2.3 Case No. No Contact Order IC 31-32-13 IC 33-39-1-8 IC 31-34 IC 35-33-8-3.2 IC 31-37 Workplace Violence Restraining Order IC 34-26-6 IC 35-33-8-3.6 IC 35-38-1-30 and/or 35-38-2-2.3 Court INDIANA County PETITIONER/PROTECTED PERSON/CHILD'S NAME IF CHILD IS PROTECTED PERSON PETITIONER/PROTECTED PERSON IDENTIFIERS BIRTH YEAR SEX RACE First Middle Last Other Protected Persons/Birth Year/Sex/Race: And/or on behalf of minor family member(s):[List name, Sex, Race & Birth Year] _________________________________________________________________________________________________ _________________________________________________________ _________________________________________________________ ________________________________________________________ ________________________________________________________ _______________________________________________________ V. RESPONDENT/DEFENDANT SEX RESPONDENT/DEFENDANT IDENTIFIERS RACE DOB HT WT First Middle Last EYES HAIR DISTINGUISHING FEATURES Relationship between Petitioner/Protected Person: __________ _______________________________________________ Respondent's/Defendant's Address: ____________________ DRIVERS LICENSE # STATE EXP DATE _______________________________________________ CAUTION: Weapon Involved Weapon Present on the property THE COURT FINDS: That it has jurisdiction over the parties and subject matter, and the Respondent/Defendant has been or will be provided with reasonable notice and opportunity to be heard. Additional findings of this order follow on succeeding pages. THE COURT ORDERS: The Respondent/Defendant is restrained from committing further acts of abuse or threats of abuse to the Petitioner/Protected Person. ____Yes ____ No The Respondent/Defendant is Brady disqualified. ___ The Respondent/Defendant is restrained from any contact with the Petitioner. OR ___ The Respondent may only contact the Petitioner in the conditions in paragraph (s) ____ of the order. Additional terms of this order follow on succeeding pages. The terms of this order shall be effective until: (Check Only One) ______________________________________ [date] further order of the court. WARNINGS TO RESPONDENT/DEFENDANT: This order shall be enforced, even without registration, by the courts and law enforcement personnel of any state, the District of Columbia, any U.S. Territory, and may be enforced by Indian Tribal Government (18 U.S.C. Section 2265). Crossing state, territorial, or tribal boundaries to violate this order may result in Federal imprisonment (18 U.S.C. Section 2262). Federal law provides penalties for possessing, transporting, shipping, or receiving any firearm or ammunition (18 U.S.C. Section 922(g)(8)). Only the Court can change this order. [The following court information is required by statute.] Court Phone ( ) To verify status, call: Clerk ( Page 1 of _____ ) Court Hours: Sheriff ( ) American LegalNet, Inc. www.FormsWorkFlow.com TCM-PO-Cover Sheet Approved 07/02 Rev. by State Ct. Admin. 07/15