DO NOT SERVE OR SHOW THIS SHEET TO RESPONDENT FOR USE BY LAW ENFORCEMENT ONLY * Case Number This completed form is required by law enforcement to enforce your order. Fill in the following information as completely as possible. Type or print only. Addresses, birthdates and Social Security numbers of both parties are necessary to serve and enforce your order. LAW ENFORCEMENT INFORMATION * Name of Petitioner (First, Middle, Last) Current Address *Birthdate/Age PHONE Home: Work: PETITIONER INFORMATION Emergency Contact Name / Address / Phone RESPONDENT INFORMATION Height Weight * Name of Respondent (First, Middle, Last) *Sex *DOB * Race Interpreter Req? Language * Social Security Number or ID Number (specify) Eye Color Hair Color * Relationship to Petitioner Scars/Marks/Tattoos/Piercings Description - Location Respondent to be served at: Home Phone Employer Vehicle License Number Employer's Address Vehicle Make and Model WORK Hours: Phone: Vehicle Color Vehicle Year PERSONS PROTECTED BY THIS ORDER * (MUST LIST ALL REQUESTED INFORMATION) Name / Birthdate / Social Security Number / Race / Sex 1. (Petitioner)* 2. (Child) 3. (Child) 4. (Child) 5. (Other) 6. (Other) HAZARD INFORMATION Itemize/Explain: Weapons Guns/Rifles Knives Explosives Other Location of Weapons: Vehicle On Person Residence CURRENT STATUS Are you and the respondent living together right now? Does the respondent know you are trying to get this order? Does the respondent know he/she may be moved out of home? Is the respondent likely to react violently when served? (Circle) Yes Yes Yes Yes No No No No Respondent's History Includes: Mental Health Problems (Commitment, Treatment, Suicide Attempt, Other) Assault Assault with Weapons Alcohol / Drug Abuse Active Warrant for Arrest _________________________________________ (Give name of Court, if known) * These information items must be provided for the Protection Order to be entered into the NCIC law enforcement data system. See Reverse for Additional Information Prepared by: Date: DR-82 (9/14) Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com