PO-0120 Approved 07-01-02 Revised 07-11-08 CONFIDENTIAL DATA ENTRY FORM FOR FOREIGN PROTECTION ORDERS For use by Court, Clerk, Prosecuting Attorney and Law Enforcement Personnel ONLY DIVISION OF STATE COURT ADMINISTRATION Note: The following information is confidential under Indiana law pursuant to Indiana Code § 5-2-9-7, and it may not be released. STATE OF INDIANA ) COURT: Superior, Room #: _________ COUNTY OF _________ ) (check one) Circuit _______________________________________________ CASE #: _________-________-_____-_________ PETITIONER/PROTECTED PERSON v. _______________________________________________ DATE: ___________ m/d/yyyy RESPONDENT/DEFENDANT PERSON PROTECTED Does the protected person live within a municipal boundary? Yes No (i.e., within city/town limits) Name: Home address: If yes, which municipality? SSN: (optional) DOB: Race: male female Sex: Postal address (if different from home address): ______________________ Telephone No.: Home: (______)___________________ Work: (______)___________________ When can protected person be reached at the above numbers or any alternative numbers? List the cities/counties where the protected person would like a copy of the order sent: ___________________________________________________ ___________________________________________________ ___________________________________________________ Other protected address: PERSON RESTRAINED Telephone No.: Name: Home address: Home: (______)___________________ Work: (______)___________________ Postal address (if different from home address): Location of place of business or where person is usually or often found: Sex: DOB: male Any scars or tattoos? Race: female SSN: Yes Hair color: Describe nature and location of any scars or tattoos: No Height: Weight: List the name(s), dates of birth [DOB], race, and sex of any person(s) residing at the household of the protected person. Attach an additional sheet of paper if necessary. Name: DOB: Race: Sex: Male Female Name: DOB: Race: Sex: Male Female American LegalNet, Inc. www.FormsWorkflow.com 1 PO-0120 Name: Approved 07-01-02 Revised 07-11-08 DOB: Race: Sex: Male Female Name: DOB: Race: Sex: Male Female Name: DOB: Race: Sex: Male Female Name: DOB: Race: Sex: Male Female Name: DOB: Race: Sex: Male Female Name: DOB: Race: Sex: Male Female SECTION I. TERMS AND CONDITIONS OF FOREIGN PROTECTION ORDER [check all that apply] 01 The Respondent/Defendant is restrained from assaulting, threatening, abusing, harassing, following, interfering with, or stalking the Petitioner/Protected Person and/or the child of the Petitioner/Protected Person. 02 The Respondent/Defendant shall not threaten a member of the Petitioner/Protected Person’s family or household. 03 The Petitioner/Protected Person is granted exclusive possession of the residence or household. 04 The Respondent/Defendant is required to stay away from the residence, property, school or place of employment of the Petitioner/Protected Person or other family or household member. 05 The Respondent/Defendant is restrained from making any communication or contact with the Petitioner/Protected Person(s), including but not limited to, personal, written, or telephone contact, or their employer, employees, or fellow workers, or others with whom the communication would be likely to cause annoyance or alarm to the Petitioner/Protected Person(s). 06 The Respondent/Defendant [not the Petitioner/Protected Person] is awarded temporary custody of the children named. 07 The Respondent/Defendant is prohibited from possessing and/or purchasing a firearm or other weapon or ammunition. 08 Special terms and conditions of the Foreign Protection Order. Please comment: ___________________________________________________________________________________ ___________________________________________________________________________________. American LegalNet, Inc. www.FormsWorkflow.com 2 PO-0120 Approved 07-01-02 Revised 07-11-08 SECTION II. COMPLETE THIS SECTION FOR AN EXTENSION OR MODIFICATION REASON FOR EXTENSION OR MODIFICATION _____(a.) Extended due to: _______ motion for continuance. Hearing date moved to:_____________(date). Conditions of the Order remain unchanged. _______ renewal of existing Order; termination date changed to:____________(date). See attached Order. Conditions of the Order remain unchanged. ______(b.) Modified due to: _________Petitioner’s/Protected Person’s or Respondent’s/Defendant’s change of address (NOTE: Section IV of this Form needs to be completed ONLY WHEN this applies). _________ conditions of the Order have been modified. See attached Order. _________other. See attached Order. Date Order was issued:__________________________________________________________ Date Order was modified or extended:_________________________________________________________ Date Order will be terminated:_______________________________________________________________ SECTION III. COMPLETE THIS SECTION FOR A TERMINATION REASONS FOR TERMINATION _____ _____ _____ _____ _____ _____ Order Expiration of Order. The case was a criminal case and the case was dismissed. The case was a civil case and the case was dismissed. The Order was vacated. Court Order. A Protective Order hearing was held, the Ex Parte Order for Protection was terminated, and a new Protective has been issued. Other information (if any): SECTION IV. COMPLETE THIS SECTION FOR A CHANGE OF ADDRESS American LegalNet, Inc. www.FormsWorkflow.com 3 PO-0120 Approved 07-01-02 Revised 07-11-08 Name of Petitioner/Protected Person:__________________________________________________________ Date of birth: ____________________ Sex: Male [ ] Female [ ] Race: ____________________________ Address:______________________________ Alternate address:__________________________________ _____________________________________ _________________________________________________ _____________________________________ _________________________________________________ Telephone Number:_____________________ Alternate Tel. #:_______________________ Within a municipal boundary? Yes ( ) No ( ) Within a municipal boundary? Yes ( ) No ( ) Which municipality?____________________ Which municipality? ________________________ _____________________________________ __________________________________________ Social Security Number (optional):________________________ Name of Respondent/Defendant:_____________________________________________________________ Address:____________________________________________________________________________ Telephone Number:___________________________________________________________________ Date of birth:________________ Social Security Number (if known):___________________________ Sex: Male ( ) Female ( ) Race:____________________________ SECTION V. FOR USE BY CLERK OF COURT A copy of this Confidential Data Entry Form for Foreign Protection Orders has been sent to the following Depositories: _______ Sheriff of ______________________________________________ County. _______ Any other sheriff or enforcement agency of a municipality listed in this Form: Name(s) of county(ies):_____________________________________________________________. Name(s) of municipality(ies):________________________________________________________. The copy was transmitted on (date):______________________________ by (name of person transmitting copy):_____________________________________. American LegalNet, Inc. www.FormsWorkflow.com 4