PO-0105 Approved 07-01-02 Revised 07-01-09 STATE OF INDIANA ) ) SS: COUNTY OF ________ ) IN THE ________________COURT___ (___________ DIVISION, ROOM ____) CASE NO._________________________ _______________________,) Petitioner ) vs. ) _______________________,) Respondent ) EX PARTE ORDER FOR PROTECTION The Court, under the authority of Indiana Code § 34-26-5-9 (b), issues this Ex Parte Order for Protection. FINDINGS The Court, having reviewed the Petition and/or hearing testimony, now makes the following Findings: a. The Petitioner has shown, by a preponderance of the evidence, that domestic or family violence, stalking, or a sex offense has occurred sufficient to justify the issuance of this Order. b. This order does / does not protect an intimate partner or child. c. The Respondent represents a credible threat to the safety of the Petitioner or a member of the Petitioner’s household. d. The following relief is necessary to bring about a cessation of the violence or the threat of violence. IDACS Codes: ORDER (Check all applicable relief ordered) ___1. The Respondent is hereby enjoined from threatening to commit or committing acts of domestic or family violence, stalking, or a sex offense against the Petitioner and the following designated family or household members, if any: __________________________________________________________________ __________________________________________________________________ _________________________________________________________________. ___2. The Respondent is prohibited from harassing, annoying, telephoning, contacting, or directly or indirectly communicating with the Petitioner, except: ___________ __________________________________________________________________ __________________________________________________________________ ___3. The Respondent shall be removed and excluded from the Petitioner’s residence. 01 Petitioner 02 - Others 05 03 Page 2 of ____ pages American LegalNet, Inc. www.FormsWorkFlow.com PO-0105 Approved 07-01-02 Revised 07-01-09 ___4. The Respondent is ordered to stay away from the residence, school, and/or place of employment of the Petitioner. The Respondent is further ordered to stay away from the following place(s) that is/are frequented by the Petitioner and/or the Petitioner’s family or household members: ______________________________ ________________________________________________________________. ___5. The Petitioner shall have the possession and use of the residence/motor vehicle/other essential personal effects as follows: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________. ___6. The Court orders the following additional relief to provide for the safety and welfare of the Petitioner and each family or household member designated in Paragraph 1 of this Order: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________. ___7. To law enforcement officers: You are hereby directed to accompany the Petitioner to the residence of the parties to ensure that the Petitioner is safely restored to the possession of the residence/motor vehicle/other essential personal effects listed above; and/or, you are to supervise the Petitioner’s or Respondent’s removal of personal belongings. 04 03 – Residence 08 - Other 08 08 THIS EX PARTE ORDER FOR PROTECTION EXPIRES: ____ TWO (2) YEARS FROM THE DATE IT IS ISSUED; OR ____ ON THE _____ DAY OF ______________________, 20___. THE RESPONDENT IS ORDERED TO PAY COURT COSTS TO THE CLERK IN THE AMOUNT OF $_____ UNDER INDIANA CODE § 34-26-5-16. DATE: __________ Recommended for approval by, if applicable: _____________________________________ ____________, COMMISSIONER/REFEREE Approved and ordered by: _____________________________________ ________________, JUDGE/MAGISTRATE ******IMPORTANT NOTICE****** Page 3 of ____ pages American LegalNet, Inc. www.FormsWorkFlow.com PO-0105 Approved 07-01-02 Revised 07-01-09 VIOLATION OF THIS ORDER IS PUNISHABLE BY CONFINEMENT IN JAIL, PRISON, AND/OR A FINE. IF SO ORDERED BY THE COURT, THE RESPONDENT IS FORBIDDEN TO ENTER OR STAY AT THE PETITIONER’S RESIDENCE OR RESIDENCE OF ANY CHILD WHO IS THE SUBJECT OF THE ORDER, EVEN IF INVITED TO DO SO BY THE PETITIONER OR ANY OTHER PERSON. IN NO EVENT IS THE ORDER FOR PROTECTION VOIDED. PURSUANT TO 18 U.S.C. 2265, THIS ORDER FOR PROTECTION SHALL BE GIVEN FULL FAITH AND CREDIT IN ANY OTHER STATE OR TRIBAL LAND AND SHALL BE ENFORCED AS IF IT WERE AN ORDER ISSUED IN THAT STATE OR TRIBAL LAND. PURSUANT TO 18 U.S.C. 922(g), ONCE A RESPONDENT HAS RECEIVED NOTICE OF THIS ORDER AND AN OPPORTUNITY TO BE HEARD, IT IS A FEDERAL VIOLATION TO PURCHASE, RECEIVE, OR POSSESS A FIREARM WHILE SUBJECT TO THIS ORDER IF THE PROTECTED PERSON IS: (A) THE RESPONDENT’S CURRENT OR FORMER SPOUSE; (B) A CURRENT OR FORMER PERSON WITH WHOM THE RESPONDENT RESIDED WHILE IN AN INTIMATE RELATIONSHIP; OR (C) A PERSON WITH WHOM THE RESPONDENT HAS A CHILD. INTERSTATE VIOLATION OF THIS ORDER MAY SUBJECT THE RESPONDENT TO FEDERAL CRIMINAL PENALTIES UNDER 18 U.S.C. 2261 AND 18 U.S.C. 2262. YOU HAVE THE RIGHT TO REQUEST THAT A HEARING BE HELD ON THE ISSUES OF THIS CASE. YOU MUST REQUEST THE HEARING IN WRITING WITHIN THIRTY (30) DAYS OF RECEIVING THIS ORDER. IF REQUESTED, THE COURT STAFF/CLERK WILL PROVIDE YOU WITH THE FORMS CONTAINING THE REQUIRED INFORMATION YOU NEED TO SUBMIT TO OBTAIN A HEARING IN THIS CASE. Page 4 of ____ pages American LegalNet, Inc. www.FormsWorkFlow.com