COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : Index No. DOMESTIC VIOLENCE PROTECTION ORDER INFORMATION SHEET : Calendar No. INSTRUCTIONS TO APPLICANT: Please provide all information know to you. BOLD FIELDS ARE MANDATORY : APPLICANT DATA Plaintiff(s) -against- List person(s) requesting protection order: : Full Name(s) : JUDICIAL SUBPOENA ________________________ _______________ _____ (Last) (First) (Middle) (Last) (First) (Middle) : ________________________ _______________ _____ ________________________ _______________ _____ Defendant(s) : (Last) Date of Birth Race _________ ________ (MM/DD/YY) ________ (MM/DD/YY) _________ _________ . . . . . . . . . . . . . . . . . . . . . . . . . . . . (First). . . . . . . . . . . . . . . . . . .(Middle) ... .... (MM/DD/YY) ________ Gender ___ ___ ___ ADVERSE PARTY DATA Full Name:________________________________________________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK (Last) (First) (Middle) TO Relationship to you:_______________________________________________________________________________________________ Other Name used:___________________________________________________________________________________________ (Last) (First) (Middle) GREETINGS: Home Address:_______________________________________________________ Bldng#_________ Apt #_______________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before City:_____________________________State:_________________Zip:______________________ the Honorable at the , Court Home Phone:________________________________________________________ located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Occupation:___________________________________ Employers Name:_____________________________________________________ Work Address:_____________________________________________________________________________________________________ City:________________________ State:__________ Zip:__________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Work Phone:_____________________________ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Work Days:___________________________ Work Hours:_______________________________________________________________ Witness, Honorable DATE OF BIRTH:________________________ and/or (MM/DD/YY) Court in County, day of , one of the Justices of the SOCIAL SECURITY NO: ________________________________________ , 20 Hair Color:_____________Eye Color:_______________ Height: ______ Weight:________Gender: ________ Race:_______ Scars/Marks/Tattoos Description & Location: ____________________________________________________________________________ Vehicle Make:_________________________ Model:_________________Year:__________ License Plate #/State:____________________ (Attorney must sign above and type name below) Are you and the Adverse Party living together now? (Yes or No) ___________________ Are you and the Adverse Party employed by the same employer? (Yes or No) ___________________ Attorney(s) for Is the Adverse Party likely to react violently when served with the TPO? (Yes or No) ___________________ Is the Adverse Party likely to avoid service? (Yes or No) ___________________ Does the Adverse Party have access to weapons? (Yes or No) ___________________ Does the Adverse Party have a Carrying Concealed Weapon (CCW) permit? (Yes or No) ___________________ If yes, please describe type and location: __________________________________________________ Office and P.O. Address Does the Adverse Party’s history include (please circle): assaults, assaults w/weapon, batteries, mental health problems, drug/alcohol abuse, outstanding/prior arrest warrants, other?_______________________________________________________________________________________________________________________ DO NOT WRITE IN THIS SPACE. FOR COURT USE ONLY Telephone No.: Issuing Court ORI: NV016015J Facsimile No.: Court Case No.:___________________ Brady Y/N:_____________________ E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com