STATE OF INDIANA ) ) SS: COUNTY OF ___________ ) IN THE ________________COURT ____ (_____________ DIVISION, ROOM ____) CASE NO._________________________ _______________________, ) Petitioner ) vs. ) _______________________, ) Respondent (Your Name) ) RESPONDENT'S VERIFIED REQUEST FOR A HEARING On ________________________, this Court issued (strike through the language that does not apply) an Ex Parte Order for Protection/an Ex Parte Modification of an Order for Protection. I, the undersigned Respondent, received a copy of the Order on ____________________________. Comes now the Respondent, within thirty (30) days of receipt of service of the Order, and pursuant to Indiana Code § 34-26-5-10(a) requests that the Court hold a hearing on the issues in this case. The address and daytime telephone number I wish the Court and opposing party to use in order to contact me about this case is as follows: ___________________________________________________ ______________________________________________________________________. I affirm, under the penalties for perjury, that the foregoing representations are true. DATE: ________ (Respondent's Signature)__________________________ (Printed) __________________________ TCM-PO-0107 Approved 07/02 Rev. by State Ct. Admin. 07/08 American LegalNet, Inc. www.FormsWorkFlow.com