FORM 10-A: PROTECTION NOTICE TO NCIC New Form Modification of Previous Form (Required fields appear in bold print) SUBJECT NAME (LAST) (FIRST) (M.I.) ADDRESS PHYSICAL DESCRIPTION: (STREET) HGT (CITY) WGT HAIR (STATE) EYES RACE (ZIP) SEX NUMERICAL IDENTIFIER (NOTE: Only ONE of the 4 numerical identifiers is needed.) 1. SSN / / 2. DOB / 3.* DRIVERS LIC. NO. STATE EXPIRATION YR. 4.* VEHICLE LIC. NO. STATE EXPIRATION YR. (* If #3 or #4 is used as a numerical identifier, entire line MUST be completed.) / LIC. TYPE BRADY HANDGUN DISQUALIFIERS: (18 U.S.C. § 922(d)(8) requires all “yes” to disqualify subject from purchasing a handgun) Does order protect an intimate partner or child(ren)? Did subject have opportunity to participate in hearing regarding order? Does order find subject a credible threat or explicitly prohibit physical force? IS THE SUBJECT BRADY DISQUALIFIED? CASE / ORDER NO. YES YES YES YES NO NO NO NO (15 DIGIT MAXIMUM) COURT ORIGINATING AGENCY IDENTIFIER R.C. 2903.213 R.C. 2919.26 R.C. 2903.214 R.C. 3113.31 DATE OF ORDER / / (9 DIGIT ORI ASSIGNED BY NCIC) NAME OF JUDGE EXPIRATION OF ORDER / / (IN R.C. 2919.26 CASES, NONEXP MAY BE USED) TERMS AND CONDITIONS OF ORDER (Mark all that are applicable) : 01 The subject is restrained from assaulting, threatening, abusing, harassing, following, interfering, or stalking the protected person and/or the child(ren) of the protected person. 02 The subject shall not threaten a member of the protected person’s family or household. 03 The protected person is granted exclusive possession of the residence or household. 04 The subject is required to stay away from the residence, property, school, or place of employment of the protected person or other family or household member. 05 The subject is restrained from making any communication with the protected person, including but not limited to, personal, written, or telephone contact, or their employer, employees, or fellow workers, or others with whom the communication would be likely to cause annoyance or alarm the victim. 06 The subject has visitation or custody rights of the children named in this order. 07 The subject is prohibited from possessing and/or purchasing a firearm or other weapon. 08 See the Miscellaneous Field for comments regarding the specific terms and conditions of the order. Miscellaneous comments: OHP DATA ONLY 09 The protected person is awarded temporary exclusive custody of the children named. LIST ALL PROTECTED PERSONS (Total of 9 allowed, may attach additional forms; SSN is NOT necessary if DOB is given): #EPO PROTECTED PERSON (LAST) DOB / (FIRST) / SSN / SSN / SSN / / (M.I.) RACE SEX PROTECTED PERSON (LAST) DOB MIS/ / (FIRST) / / (M.I.) RACE SEX PROTECTED PERSON (LAST) DOB / Authorized by (signature): (circle one) (FIRST) / / (M.I.) RACE SEX Date Judge/Magistrate American LegalNet, Inc. Form 10-A May be reproduced locally 9/1/04 www.USCourtForms.com Discard all previous versions of this form