PO-0113 Approved 07-01-02 Revised 07-01-09 STATE OF INDIANA COUNTY OF ________ ) ) SS: ) IN THE ________________COURT ____ (______________ DIVISION, ROOM __) CASE NO._________________________ _______________________, ) Petitioner ) vs. ) _______________________, ) Respondent ) ORDER FOR PROTECTION FINDINGS This matter having been heard by the Court on ____________________ pursuant to Indiana Code § 34-26-5-10, the Court now makes the following Findings (strike through those which do not apply): a. _______________________ filed a timely Request for Hearing pursuant to Indiana Code § 34-26-5-10(a); and/or, b. The Court is required to hold a hearing pursuant to Indiana Code § 34-26-5-10(b). c. The Petitioner was present at the hearing and the Respondent was / was not present. d. This order does / does not protect an intimate partner or child. e. The Respondent had notice and an opportunity to be heard. f. The Respondent represents a credible threat to the safety of the Petitioner or a member of the Petitioner’s household. g. The Petitioner has shown, by a preponderance of the evidence, that domestic or family violence, a sex offense, or stalking has occurred sufficient to justify the issuance of this Order. h. The Respondent does/does not agree to the issuance of the Order for Protection. i. The following relief is necessary to bring about a cessation of the violence or the threat of violence. ORDER (strike through those which do not apply) Section 1—General Provisions 1. The Respondent is hereby enjoined from threatening to commit or committing acts of domestic or family violence, stalking and sex offenses against the Petitioner and the following designated family or household members, if any: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________. IDACS Codes: 01 Petitioner 02 - Others Page 2 of ____ pages American LegalNet, Inc. www.FormsWorkFlow.com PO-0113 Approved 07-01-02 Revised 07-01-09 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. 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; or, you are to supervise the Petitioner’s or Respondent’s removal of personal belongings. 8. The Respondent is prohibited from using or possessing a firearm, ammunition, or deadly weapon. The Respondent is ordered to surrender the following firearm[s], ammunition, and/or deadly weapon[s] which the Court finds are in the control, ownership, or possession of the Respondent or in the control or possession of another person on behalf of the Respondent: a. ___________________________________________________; b. ___________________________________________________; c. ___________________________________________________; (attach a separate sheet if necessary). 9. The Respondent shall surrender the items listed above between the hours of __:__ and __:___ on the date of ________________ to the following law enforcement agency ____________________________ at the following location: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________. 10.The law enforcement agency listed above shall provide the Respondent with a receipt for the items the Court has ordered the Respondent to surrender. The law enforcement agency shall also provide the Court with written verification of the Respondent’s compliance with this Order no later than one (1) business day after such compliance. 05 03 04 03 – Residence 08 - Other 08 08 07 08 08 Page 3 of ____ pages American LegalNet, Inc. www.FormsWorkFlow.com PO-0113 Approved 07-01-02 Revised 07-01-09 If the Respondent does not appear at the specified date and time, or appears but does not have all of the items listed above, the law enforcement agency is ordered to contact the Court immediately by the following means: ________________________________________________________________. 11.The items listed above shall be kept by the law enforcement agency for the duration of this Order or until the following date: _________________________. (if the parties do not have children, proceed to Section 3) 08 Section 2—Parenting Provisions 12. The arrangements for parenting time of [a] minor child[ren] by the Respondent shall 08 be as follows (strike through those which do not apply): a. The Court finds that it is necessary to deny parenting time at this time in order to protect the safety of the Petitioner and/or the minor child[ren] in question; or, b. The Court finds that it is necessary that parenting time be supervised by a third (3rd) party in order to protect the safety of the Petitioner and/or the minor child[ren] in question. Parenting time shall occur only under the following conditions: i. Parenting time shall take place every ______________ from ______ __.m. to ______ __.m. at _______________________ and in the presence of the third (3rd) party, _____________________________________. The Petitioner is responsible for dropping off the child[ren] by _____ __.m. and for picking up the child[ren] by _____ __.m. In the event that parenting time cannot take place, the Petitioner or Respondent must telephone the third (3rd) party, ____________________ , at _______________, by _____ __.m., and parenting time shall then take place the following ____________ with the same provisions; ii. Respondent shall not consume any alcohol or illegal drugs during the 12 hours prior to and during parenting time. If the Respondent appears to have violated this provision, the third (3rd) party is authorized to deny the Respondent parenting time on that occasion. The third (3rd) party is also required to file a written report of the incident with this Court on the next business day. iii. Parenting time is conditioned upon the Respondent receiving weekly counseling for_____________________________________ from ____________________________________, Page 4 of ____ pages American LegalNet, Inc. www.FormsWorkFlow.com PO-0113 Approved 07-01-02 Revised 07-01-09 for a length of time to be no less than ________________________________________; iv. Parenting time may be denied if the Respondent is more than 30 minutes late and does not call by 8:30 a.m. on the day the parenting time is scheduled to occur to alert the third (3rd) party of this fact; v. The Petitioner must arrive at the drop-off location 20 minutes before the Respondent, and then leave before the Respondent arrives. At the end of the parenting time, the Respondent must remain at the location for 20 minutes while the Petitioner leaves with the child[ren]; vi. If the Respondent wishes to exercise parenting time rights, the Respondent must call the third (3rd) party, ________________, at __________________, by 10:00 a.m. on the day before each scheduled parenting time. The third (3rd) party, ________________________________, shall then call the Petitioner; or, c. Parenting time shall be unsupervised and shall occur as follows: i. __________________________________ __________________________________ __________________________________ __________________________________. 13. The Court now sets a hearing to review the terms of this Order with respect to parenting time. The parties are ordered to appear without further notice in this Courtroom on the following date and time: ________________________________. (if monetary relief is not ordered, proceed to Section 4) Section 3—Monetary Relief 14.The Respondent is ordered to pay the Petitioner’s attorney fees in the amount of: $_________ on or before _________________________. The payment shall be made at the following location: _______________________________ and in the following form: __________________. The Petitioner’s attorney shall provide the Respondent a receipt for the payment. 15.The Respondent is ordered to pay rent or to make payments on the mortgage at the Petitioner’s residence in the amount of: $____________ per week/month. The payment shall be made at the following location:______________________ and in the following form: _________________. The Respondent shall be provided with receipts for the payments by the following person or entity: ________________________________. 16.The Court finds that the Respondent owes a duty of child support for the following minor child[ren]:______________________________________________________. 17.The Court finds that the Respondent owes a duty of support to the Petitioner. 18.The Respondent shall pay child support/support to the Petitioner as follows: payments of $__________ per week/month according to the child support worksheet Page 5 of ____ pages American LegalNet, Inc. www.FormsWorkFlow.com 08 08 08 08 08 PO-0113 Approved 07-01-02 Revised 07-01-09 attached. Payments from employers shall be made to the Indiana State Central Collection Unit, P.O. Box 6219, Indianapolis, IN 46206-6219 via an income withholding order. Payments from non-custodial parents should be made to the Indiana State Central Collection Unit, P.O. Box 7130, Indianapolis, IN 46207-7130. 19. The 6% Rule shall apply, with the (Petitioner) (Respondent) paying the first $ ____ of the total medical, dental, optical and orthodontia expenses not covered by insurance. Thereafter, the Petitioner shall pay ___ % of such uncovered expenses and the Respondent shall pay ___ % . 20.The Respondent is ordered to reimburse the Petitioner or the following specified person, ________________________________, for expenses related to family or domestic violence: a. medical expenses $_____________________ b. counseling $_____________________ c. shelter $_____________________ d. repair or replacement $_____________________ of damaged property e. costs/fees incurred $_____________________ by the Petitioner in bringing this action TOTAL: $______________________. Such payment is to be made at the following location:_________________ and in the following form: _____________________. The Respondent shall be provided with receipts for the payments by the following person or entity: ________________________________________________________. Section 4—Duration of Order THIS ORDER FOR PROTECTION EXPIRES: ____ TWO (2) YEARS FROM THE DATE IT IS ISSUED; OR ____ ON THE _____ DAY OF __________________, 2____. 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: _____________________________________ Page 6 of ____ pages American LegalNet, Inc. www.FormsWorkFlow.com 08 08 PO-0113 Approved 07-01-02 Revised 07-01-09 ________________, JUDGE/MAGISTRATE ******IMPORTANT NOTICE****** 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. Page 7 of ____ pages American LegalNet, Inc. www.FormsWorkFlow.com