Case Identification Information For Confidential Form. This is a Indiana form and can be use in Protective Order Statewide.
Tags: Case Identification Information For Confidential Form, PO-0104, Indiana Statewide, Protective Order
CASE IDENTIFICATION INFORMATION FOR CONFIDENTIAL FORM For use by Court, Clerk, Prosecuting Attorney, and Law Enforcement Personnel ONLY DIVISION OF STATE COURT ADMINISTRATION STATE OF INDIANA ) COURT: Superior, Room #: _________ COUNTY OF _________ ) (check one) Circuit _______________________________________________ CASE #: _________-________-_____-_________ PETITIONER/PLAINTIFF/STATE OF INDIANA v. _______________________________________________ DATE: ___________ mm/dd/yyyy RESPONDENT/DEFENDANT _______________________________________________ EMPLOYEE (IF WVRO) PERSON RESTRAINED Name: Home: (______)_____________________ Work: (______)_____________________ Cell: (______)_____________________ Email: __________________________________________ Home address: Postal address (if different from home address): Sex: DOB: male Any scars or tattoos? Race: Location of place of business or where person is usually or often found: female Describe nature and location of any scars or tattoos: Yes No Hair color: Eye Color: Height: Weight: List the name(s), age, race, and sex of any person(s) residing at the household of the protected person. Attach an additional sheet of paper if necessary. Name: Age: Race: Sex: Male Female Name: Age: Race: Sex: Male Female Name: Age: Race: Sex: Male Female Name: Age: Race: Sex: Male Female Name: Age: Race: Sex: Male Female 1 American LegalNet, Inc. www.FormsWorkFlow.com TCM-PO-0104 Approved 07/02 Rev. by State Ct. Admin. 04/11 NOTE: This portion must be completed when a protection, no-contact, workplace violence restraining order is requested. The information provided on this form will be used to update the statewide protective order database for the enforcement of the order. CONFIDENTIAL FORM Note: The following information is confidential under Indiana law pursuant to Indiana Code § 5-2-9-7, and it may not be released. PETITIONER Home address: DOB: Race: Sex: SSN: (optional) male Home: Work: Fax: Cell: Email: female (______)_____________________ (______)_____________________ (______)_____________________ (______)_____________________ __________________________________________ PROTECTION ORDERS ONLY: Yes No Do you wish to receive notifications when the order is issued, served, and about to expire? Email Text Fax Method: Cell Phone Service Provider (if you selected Text as the notification method): __________________________ You must provide data in the proper fields above to match the Method of notification chosen. See Notification Information at the bottom of this form. Postal address (if different from home address): When can protected person be reached at the above numbers or any alternative numbers? Other protected address: Address from confidentiality program of Attorney General: List the cities/counties where the protected person would like a copy of the order sent: _____________________________________________________ _____________________________________________________ _______________________________________________ PERSON RESTRAINED SSN: ___________________________________ End of Confidential Form. The “Confidential Form” portion of this form must be on green paper according to Admin. Rule 9 Notification Information • The user will incur standard text-messaging fees for any messages received. • The user is responsible to notify the Clerk’s office of any changes to their contact information which may include their cell phone number and email address. • The Indiana Supreme Court’s Division of State Court Administration may not be held liable for the failure of the receipt of a notification. • The notifications sent to users are a service being provided by the Indiana Supreme Court’s Division of State Court Administration. • Cell Phone Service Providers Supported: Alltel, AT&T, Boost, Cellular South, Centennial Wireless, Cincinnati Bell, Cricket Wireless, Metro PCS, Powertel, Qwest, Rogers, Sprint, Suncom, Telus, T-Mobile, US Cellular, Verizon Wireless, Virgin Mobile 2 American LegalNet, Inc. www.FormsWorkFlow.com TCM-PO-0104 Approved 07/02 Rev. by State Ct. Admin. 04/11