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Order For Protection (Issued After Hearing) (Short Form) Form. This is a Indiana form and can be use in Protective Order Statewide.
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Tags: Order For Protection (Issued After Hearing) (Short Form), PO-0112, Indiana Statewide, Protective Order
PO-0112
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
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PO-0112
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:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________.
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Residence
08 - Other
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PO-0112
Approved 07-01-02
Revised
07-01-09
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.
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)
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Section 2—Parenting Time Provisions
12. The Court, having found that domestic or family violence has occurred, now orders,
pursuant to Indiana Code § 34-26-5-9(c)(2):
a.
Respondent’s parenting time shall be supervised by a third party
and/or limited as follows: _____________________________
__________________________________________________
__________________________________________________;
or,
b.
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
c.
Parenting time shall be unsupervised and shall occur as follows:
___________________________________________________
___________________________________________________
___________________________________________________.
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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.
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PO-0112
Approved 07-01-02
Revised
07-01-09
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 in the sum of
$__________ per week/month, according to the Child Support Guidelines Worksheet
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:
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PO-0112
Approved 07-01-02
Revised
07-01-09
____ 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:
_____________________________________
________________, 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.
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