IN THE MUNICIPAL COURT OF THE CITY OF VANDALIA, OHIO CRIMINAL DIVISION STATE OF OHIO * * Plaintiff, CASE NO. ________________________________ JUDGE CYNTHIA M. HECK -vs- * ____________________________________________ * Defendant. MOTION FOR TEMPORARY PROTECTION ORDER * __________________________________________, (Name of person) the Alleged Victim in the above captioned case, moves the Court to issue a temporary protection order containing terms designed to ensure the safety and protection of the complainant and other family or household members, in relation to the named defendant, pursuant to its authority to issue such an order under Section 2919.26 of the Ohio Revised Code. A complaint, a copy of which has been attached to this motion, has been filed in this Court charging the Defendant with knowingly causing or attempting to cause physical harm to a family or household member, or recklessly causing serious physical harm to a family or household member, which constitutes “domestic violence,” a violation of Section 2919.25 of the Ohio Revised Code. I understand that I must appear before the Court, at a time set by the Court within twenty-four (24) hours after the filing of this motion, for a hearing on the motion, and that any temporary protection order granted pursuant to this motion is a pre-trial condition of release and is effective only until the disposition of the criminal proceeding arising out of the attached complaint or the issuance of a civil protection order or the approval of a consent agreement, arising out of the same activities as those that were the basis of the complaint, under Section 3113.31 of the Ohio Revised Code. FIREARMS ACCESS ____Yes ____No _________________________________________________________________________________ SIGNATURE OF ALLEGED VICTIM _________________________________________________________________________________ ADDRESS OF ALLEGED VICTIM _________________________________________________________________________________ CITY, STATE, ZIP CODE _____________________________________________ SSN OF ALLEGED VICTIM _____________________________________________ DOB OF ALLEGED VICTIM _____________________________________________ PHONE NUMBER OF ALLEGED VICTIM REVISED 5/01/07 American LegalNet, Inc. www.FormsWorkflow.com TEMPORARY PROTECTION ORDER SUPPLEMENTAL INFORMATION FORM In order to comply with N.C.I.C. requirements pertaining to Temporary Protection Orders, police agencies are required to be notified of the full name and date of birth of the victim and the full names and dates of birth of all persons residing in the residence who may be the subject of the order. Please supply that information in the space(s) provided below: 1) Victim: Full Name_____________________________ Date of Birth_____________________________ Social Security No._____________________________ 2) Other Person: Full Name_____________________________ Date of Birth_____________________________ Social Security No._____________________________ 3) Other Person: Full Name_____________________________ Date of Birth_____________________________ Social Security No._____________________________ 4) Other Person: Full Name_____________________________ Date of Birth_____________________________ Social Security No._____________________________ 5) Other Person: Full Name_____________________________ Date of Birth_____________________________ Social Security No._____________________________ To the best of my knowledge, the Defendant has access to firearms _____Yes _____No ___________________________________ Victim Signature 05/2004 American LegalNet, Inc. www.FormsWorkflow.com