File No. STATE OF NORTH CAROLINA In The General Court Of Justice County District Court Division Name Of Defendant IDENTIFYING INFORMATION Street Address Of Defendant (Not P.O. Box) ABOUT DEFENDANT City State Zip DOMESTIC VIOLENCE ACTION G.S. 50B-3(d) INSTRUCTIONS: In order to assist law enforcement agencies in serving and enforcing this Order, if issued by the Court, the following information is requested. It is not required for the issuance of this Order, but may allow law enforcement agencies to locate and more quickly identify the persons involved in this case and to enforce the provisions of this Order more effectively. Answer these questions accurately and honestly. If you do not know the answer to any of the following questions, leave the question blank. INFORMATION ABOUT DEFENDANT Date Of Birth Race: White Black Indian Asian/Pacific Islander Other Sex: Male FemaleHeight Weight Hair Color Eye Color Identifying Marks (List any marks, scars, tattoos) Does the defendant have a drivers license or state-issued identification card from any state? Yes No If yes, provide the state and number if possible: State: Number: Vehicle description and license plate number: Social Security No. Of Defendant Telephone No. Of Defendant The defendants current work information: Employers Business Name Business Address Business Telephone No. Defendants Work Hours (List Work Start Time And Work Stop Time) Does the defendant have a permit to purchase a handgun or crossbow? Yes No If yes, state which law enforcement agency issued the permit, if known: Does the defendant have a permit to carry a concealed handgun? Yes: No If yes, state which law enforcement agency issued the permit, if known: Is there any reason that a law enforcement officer should consider the defendant a potential threat (i.e., carries concealed weapons while drinking alcohol, has threatened an officer, etc.)? Yes No If yes, specify the circumstances: PLAINTIFF Date Of Birth Race: White Black Indian Asian/Pacific Islander Other Sex: Male FemaleDate Name Of Plaintiff (Type Or Print) Signature Of Plaintiff NOTE TO CLERK OR MAGISTRATE: If an order is issued, a copy of this form should be attached to the appropriate order and forwarded to the sheriff of the issuing court county. AOC-CV-312, Rev. 6/2000 2000 Administrative Office of the Courts Original-Court File Copy-Sheriff