STATE OF INDIANA ) )SS: COUNTY OF ____________) IN THE __________________COURT___ (_______________DIVISION, ROOM___) CASE NO.__________________________ PLAINTIFF: ___________________________________________ DEFENDANT: _________________________________________ EMPLOYEE: __________________________________________ RESPONSE TO PETITION OF EMPLOYER FOR INJUNCTION PROHIBITING VIOLENCE OR THREATS OF VIOLENCE AGAINST EMPLOYEE 1. 2. I am the person who is identified as the Defendant in this case. I received a copy of the Petition of Employer for Injunction Prohibiting Violence or Threats of Violence Against Employee on (specify date): ________________. I received a copy of the Order to Show Cause on (specify date): ______________. I (check the item that applies): a. __ agree that the facts stated in the Petition of Employer for Injunction Prohibiting Violence or Threats of Violence Against Employee are true and correct. b. __ do not agree that the facts stated in the Petition of Employer for Injunction Prohibiting Violence or Threats of Violence Against Employee are true and correct. __ I wish to make the following statement in response to the Petition of Employer for Injunction Prohibiting Violence or Threats of Violence Against Employee: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __ Continued on Attachment 5b. 3. 4. 5. Page 1 of _____ pages TCM-WV-0104 Approved 07/02 Rev. by State Ct. Admin. 07/03 American LegalNet, Inc. www.FormsWorkFlow.com 6. Number of pages attached: ______ ________________________________ (TYPE OR PRINT NAME) ______________________________ (SIGNATURE OF ATTORNEY, IF ANY) I affirm, under the penalties for perjury, that the foregoing representations are true: a. on the basis of my own personal knowledge. b. on the basis that I have been informed and believe that the facts stated are true. (NOTE: If this response is made solely on the basis of defendant's information and belief, defendant must attach affidavits by one or more persons who have personal knowledge of the facts stated.) Date: _________________________ _______________________________ (TYPE OR PRINT NAME) ______________________________ (SIGNATURE OF DEFENDANT) ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, attorney registration number, and address): TELEPHONE NO.: FAX NO.: ATTORNEY FOR (Name): Page 2 of _____ pages TCM-WV-0104 Approved 07/02 Rev. by State Ct. Admin. 07/03 American LegalNet, Inc. www.FormsWorkFlow.com