PO-0117 Approved 07-01-02 Revised 07-01-08 NOTICE OF EXTENSION OR MODIFICATION DIVISION OF STATE COURT ADMINISTRATION STATE OF INDIANA ) COUNTY OF ____________) COURT: ______________________________ _____________________________________ CASE #:__________________________________ PETITIONER/PLAINTIFF/STATE OF INDIANA V. _____________________________________ DATE: __________________________ RESPONDENT/DEFENDANT _______________________________________________ EMPLOYEE (IF WVRO) Notice is hereby given that an order previously issued under the provisions of Indiana Code § 5-2-9 has been extended or modified. PERSON PROTECTED Name: ______________________________________________________________________ Birth Year:_______________________ Race: ___________________________Sex: Male [ ] Female [ ] PERSON RESTRAINED Name: ______________________________ Telephone No.: Home:( )______________________ Date of birth:____________________ Work: ( )______________________ Sex: Male [ ] Female [ ] Race:_______________________________ Home Address:___________________________________________________________________________ Location of place of business or where person usually/often found:__________________________________ Social Security Number (if known):_____________________________________________ REASON FOR EXTENSION OR MODIFICATION _____(a.) Extended due to: _______ motion for continuance. Hearing date moved to:_____________(date). Conditions of the order remain unchanged. ______(b.) Modified due to: _________Petitioner’s/Protected Person’s or Respondent’s/Defendant’s change of address (NOTE: page 3 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:_______________________________________________________________ 1 American LegalNet, Inc. www.FormsWorkflow.com PO-0117 Approved 07-01-02 Revised 07-01-08 TYPE OF ACTION _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ No Contact Order Juvenile Court [Indiana Code § 31-32-13] Child Protective Order CHINS [Indiana Code § 31-34-2.3] No Contact Order CHINS [Indiana Code § 31-34-20] No Contact Order CHINS [Indiana Code § 31-34-25] No Contact Order Delinquency [Indiana Code § 31-37-19] No Contact Order Delinquency [Indiana Code § 31-37-25] No Contact Order Pretrial Diversion [Indiana Code § 33-14-1-7] Ex Parte Order for Protection [Indiana Code § 34-26-5] Order for Protection Issued After a Hearing [Indiana Code § 34-26-5] Workplace Violence Restraining Order—Temporary Restraining Order [Indiana Code § 34-26-6] Workplace Violence Restraining Order—Injunction [Indiana Code § 34-26-6] No Contact Order Pretrial Release [Indiana Code § 35-33-8-3.2 ] No Contact Order Condition of Probation [Indiana Code § 35-38-2-2.3] Prepared by:______________________________________________________________ Notice to Protected Person/Plaintiff: The address and telephone number listed here will not be kept confidential. The Protected Person/Plaintiff should designate a Public Mailing Address for purposes of serving pleadings, notices, and court orders. Name: ________________________________________________________________________________ Address:________________________________________________________________________________ ________________________________________________________________________________ City: _________________________________________________________________ Telephone:____________________________________ Attorney Number (if applicable): __________________ FOR USE BY CLERK OF COURT NOTICE OF EXTENSION OR MODIFICATION has been sent to the following Depositories: _______ Sheriff of ______________________________________________ County. _______ Any other sheriff or enforcement agency of a municipality named in the order: Name(s) of county(ies):_____________________________________________________________. Name(s) of municipality(ies):________________________________________________________. 2 American LegalNet, Inc. www.FormsWorkflow.com PO-0117 Approved 07-01-02 Revised 07-01-08 CONFIDENTIAL PAGE COMPLETE THIS PAGE FOR CHANGE OF ADDRESS FOR USE BY COURT, CLERK, PROSECUTING ATTORNEY, AND LAW ENFORCEMENT PERSONNEL ONLY Note: The following information is confidential under Indiana law pursuant to Indiana Code § 5-2-9-7, and it may not be released. ___________________________________ Petitioner/Plaintiff/State of Indiana vs. Case Number: ___________________________ ___________________________________ Respondent/Defendant ___________________________________ Employee (If WVRO) Date: ________________________________ Name of 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 restrained person:_____________________________________________________________ Address:____________________________________________________________________________ Telephone Number:___________________________________________________________________ Date of birth:________________ Social Security Number (if known):___________________________ Sex: Male ( ) Female ( ) Race:______________________________ 3 American LegalNet, Inc. www.FormsWorkflow.com