Enter"UNK" if data is not available. Do not hold order to collect this information FAMILY PROTECTION REGISTRY INFORMATION SHEET ****** ASTERISKED AREAS ARE REQUIRED ****** (8/2013) ** Court ORI No: NY0 __ __ __ __ __ J ** Name of Court: ** Order No: 20 ____ - __ __ __ __ __ __ ** County: ** Docket/Index No: Court Contact: Name Tel: ** Issuance Date on Order: ** Expiration Date: ** Law Enforcement Agency (Where copy of Order is Filed): Police ORI : NY **SERVICE OF ORDER: Police to Serve Order Other (later service) Order served in Court Date: Notification by Mail Mail date: (Family orders only) Order Previously Served Date: APPLYING/PROTECTED PARTY (Party Requesting Order) **Name: (First) **DOB: **Sex: M F Unk (M) 9Child (Last) 9Unborn Child 9No First Name no new service needed (Suffix) Height: Weight: Drivers ID: Eye Color: Hair Color: State: **Race: White Black Other Unk Amer. Indian/Alaskan Native Asian/Pacific Island ** Ethnicity: Hispanic Non-Hispanic Lic Plate # Soc. Sec. No.: (M) **Confidential? Yes No (Last) Type (ie Home, Work) (Apt) (Floor) Mail c/o: (County) email: State: NYSID: Mother's Maiden Name: Alias or Nickname: (First) **Address Information: ** (Street) (City) Contact Information: Phone (home): (Suffix) (Room) (Nation) fax: (State) **Confidential? Yes (work): No (Zip) 9 Outside USA (other): Against Party Relationship to Protected Party 9Spouse 9Ex-Spouse 9Father 9Mother 9Parent 9Intimate-Live Together 9Unk 9Intimate-Civil Union 9Intimate-Reg Domestic Partner 9Step-Parent 9 Other 9 Intimate-Dated Formerly 9 Intimate-Dating 9 Intimate-Other If so, have the parties ever lived together? 9 Yes 9 No Additional Protected Parties: (Please use one of the above relationships) Name: ____________________________ DOB ____________ Sex: M F Relationship to Against _____________________ Name: ____________________________ DOB ____________ Sex: M F Relationship to Against _____________________ Name: ____________________________ DOB ____________ Sex: M F Relationship to Against _____________________ If any above has an intimate-dating/former dating/other rel. with the against party, have they ever lived together? 9 Yes ENJOINED/AGAINST PARTY (Party Against Whom Order Runs) **Name: (First) **Date of Birth: (M) **Sex: Male (Last) Female Unk Height: Weight: Drivers ID: NYSID: (Last) Type (ie Home, Work) (Apt) (Floor) Mail c/o: (Zip) (County) 9 Outside USA (other): email: No (Suffix) (Room) (Nation) fax: (Suffix) 9 No Eye Color: Hair Color: State: **Race: White Black Other Unk Amer. Indian/Alaskan Native Asian/Pacific Island ** Ethnicity: Hispanic Non-Hispanic Lic Plate # State: Mother's Maiden Name: Alias or Nickname: (First) **Address Information: ** (Street) (City) Contact Information: Phone (home): Soc. Sec. No.: (M) **Confidential? Yes (State) **Confidential? Yes (work): No Is Police Caution Advised? If yes, why: American LegalNet, Inc. www.FormsWorkFlow.com