PO-0104 Approved 07-01-02 Revised 07-01-08 CONFIDENTIAL FORM 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/PLAINTIFF/STATE OF INDIANA v. _______________________________________________ DATE: ___________ m/d/yyyy RESPONDENT/DEFENDANT _______________________________________________ EMPLOYEE (IF WVRO) 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: 1 Weight: American LegalNet, Inc. www.FormsWorkflow.com PO-0104 Approved 07-01-02 Revised 07-01-08 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 Name: DOB: Race: Sex: Male Female Name: DOB: Race: Sex: Male Female Name: DOB: Race: Sex: Male Female DOB: Race: Sex: Male Female Name: DOB: Race: Sex: Male Female Name: DOB: Race: Sex: Male Female Name: NOTE: This portion of the Confidential Form must be completed when an order for protection, no-contact order, or 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. 2 American LegalNet, Inc. www.FormsWorkflow.com