Enter “UNK” if data is not FAMILY PROTECTION REGISTRY INFORMATION SHEET available. Do not hold order to collect this information ****** ASTERISKED AREAS ARE REQUIRED ****** ** Court ORI No: NY0 __ __ __ __ __ J ** Name of Court: ** Order No: 200 __ - __ __ __ __ __ __ ** County: ** Docket/Index No: Court Contact: Name ** Issuance Date on Order: ** Expiration Date: ** Law Enforcement Agency (Where copy of Order is Filed): Police Ori: (10/2005) Tel: NY **SERVICE OF ORDER: “ Police to Serve Order “ Other (later service) “ Order served in Court (Date: “ Notification by Mail (Mail date: “ Order Previously Served ( Date: Time: ) no new service to be done) APPLYING/PROTECTED PARTY (Party Requesting Order) **Name: (Prefix) 9 Child (First) 9 Unborn Child (M) ** Ethnicity: **Sex: “ Male “ White “ Black “ Other “ American Indian/Alaskan Native “ Hispanic (Suffix) (First) (City) (M) (State) Height: Weight: State: Eye Color: Hair Color: Drivers ID: State: NYSID: **Confidential? “ Yes “ No **Address Information: ** (Street) “ Unk Lic Plate # Soc. Sec. No.: Alias or Nickname: (Prefix) “ Female “ Unknown “ Asian/Pacific Islander “ Non-Hispanic Mother’s Maiden Name: Contact Information: Phone (home): (Seniority) 9 No First Name **Date of Birth: **R ace: (Last) (Zip) (Last) (Seniority) Type (ie Home, Work) (Apt) (Floor) Mail c/o: (County) **Confidential? “ Yes “ No 9 Outside USA (work): (other) : ** Is Any Protected Party the Enjoined/Against Party’s Intimate Partner, or the Child of either the Protected or Enjoined Party or 9 Yes 9 No Both" ** (Suffix) (Room) (Nation) email: fax: ** Select the relationship between Enjoined/Against Party and Protected Party: 9 Spouse 9 Ex-Spouse 9 Child-in-Common 9 Domestic Partner 9 Child of One Party ENJOINED/AGAINST PARTY (Party Against Whom Order Runs) **Name: (Prefix) (First) (M) **Date of Birth: **R ace: ** Ethnicity: **Sex: “ Male “ White “ Black “ Other “ American Indian/Alaskan Native “ Hispanic (First) (State) “ Unk (Suffix) Eye Color: Weight: State: Height: Hair Color: Drivers ID: State: NYSID: (M) **Confidential? “ Yes “ No (City) Contact Information: Phone (home): Lic Plate # Soc. Sec. No.: Alias or Nickname: (Prefix) **Address Information: ** (Street) “ Female (Seniority) “ Unknown “ Asian/Pacific Islander “ Non-Hispanic Mother’s Maiden Name: (Last) (Zip) (Last) (Seniority) Type (ie Home, Work) (Apt) (Floor) Mail c/o: (County) **Confidential? “ Yes “ No 9 Outside USA (work): (other) : email: (Suffix) (Room) (Nation) fax: Is Police Caution Advised? If yes, why? American LegalNet, Inc. www.USCourtForms.com American LegalNet, Inc. www.USCourtForms.com