DEFENDANT INFORMATION FORM DOCKET NO. (for court use only) Massachusetts Trial Court AS PROVIDED BY PLAINTIFF G.L. c. 209A or G.L. c. 258E This information is requested to help police to identify and locate the Defendant in order to serve the Defendant with a copy of any restraining Order that is issued. Please provide as much information as possible. DEFENDANT’S NAME DATE OF BIRTH OTHER NAMES USED BY DEFENDANT, IF ANY PLACE OF BIRTH MOTHER’S MAIDEN NAME (FIRST & LAST) FATHER’S NAME (FIRST & LAST) SEX HAIR RACE EYES HEIGHT SOCIAL SECURITY NO. WEIGHT PHOTO AVAILABLE? (very helpful for ID) G MALE G FEMALE G YES G NO BUILD OTHER PHYSICAL CHARACTERISTICS (beard, glasses, scars, tattoos, complexion, hairstyle) DEFENDANT’S HOME ADDRESS (NO., STREET, CITY, STATE, ZIP) APT NO. FLOOR NO. NAME ON DOOR/MAILBOX DEFENDANT’S HOME TELEPHONE NO. DOES DEFENDANT UNDERSTAND ENGLISH? G YES G NO IF NOT, WHAT LANGUAGES? DEFENDANT’S EMPLOYER/WORKPLACE WORK TELEPHONE NO. WORK ADDRESS (NO., STREET, CITY, STATE, ZIP) TITLE DEPARTMENT WORK HOURS OTHER PLACES DEFENDANT MAY BE FOUND (friends, bars, relatives, hangouts) BEST PLACE TO FIND DEFENDANT MOTOR VEHICLE LICENSE PLATE YEAR MAKE MODEL COLOR BEST TIMES TO FIND DEFENDANT DOES DEFENDANT HAVE: (describe very briefly) A history of violence toward police officers? G NO G YES A history of using/abusing drugs or alcohol? G NO G YES What kind? Access to guns, a license to carry, or possess a gun? G NO G YES What kind? Psychiatric/emotional problems? G NO G YES What kind? ANY OTHER INFORMATION WHICH MIGHT BE HELPFUL IN LOCATING THE DEFENDANT DATE SIGNED PRINT PLAINTIFF’S NAME PLAINTIFF’S SIGNATURE x FA/HA-5 (5/10) American LegalNet, Inc. www.FormsWorkFlow.com