WPF All Cases 01.0400 LEIS (6/2010) See Reverse For Additional Information LAW ENFORCEMENT INFORMATION Do NOT serve or show this sheet to the restrained person! Do NOT FILE in the c ourt f ile. Give this form to l aw e nforcement. Type or print clearly! This completed form is required by law enforcement. This information is nece ssary to serve, enforce and enter your order into the state wide law enforcement computer. Fill in the following information as completely as possib le. Court: Case Number : Domestic Violence Dissolution/Separation/Invalidity/Nonparental Custody/ Paternity Unlawful H arassment Vulnerable Adult Sexual Assault ( T his is the person that you want the court to restrain . ) Name : First Middle Last Nickname Relation ship to Protected Person Date of Birth Mal e Female Race Height Weight Eye Color Hair Color Skin Tone Build Last Known Address Street : City : State: Zip: Phone (s) w/Area Code Need Interpreter ? Yes or No Language: Employe r Employer's Address WORK Hours: Phone: ( ) Vehicle License Number Vehicle Make and Model Vehicle Color Vehicle Year Drivers License or ID number State Does the restrained person have a disability, brain injury, or impairment requiring sp ecial assistance when law enforcement serves the order ? No Yes . If yes, d escribe (continue on back, if needed): Hazard Information Involuntary/Voluntary Commitment Suicide Attempt or Threats Assault As sault with Weapons Alcohol/Drug Abuse Other: Weapons: Handguns Rifles Knives Explosives Other: Location of Weapons : Vehicle On Person Residence Describe in detail: Current Status ( C ircle Y es , N o or N/A . ) I s the restrained person a current or former cohabitant as an intimate partner? Y N Are you and the restrained person living together now? Y N Does the restrained person know he/she may be moved out of the home? Y N N/A Does the restrained person Y N Is the restrained person likely to react violently when served? Y N ( T his is the person you want the court to protect . ) Name : First Middle Last Date of Birth Ma le Female Race Height Weight Eye Color Hair Color Skin Tone Build If your information is not confidential , you must enter your address and phone number(s). Current Address Street : City : State : Zip : Phone (s) w/Area Code Need interpreter ? Y es or N o Language: If your information is confidential , you must Contact Name Contact Address Contact P hone If you filed for someone else, list your n ame , phone number and address : M lationship using terms such as: child, grandch ild, stepchild, nephew, none. Protected Restrained Name : First Middle Last Sex Race Birth date Resides With Person Person M embers or Adult Children P rotected Name: birth date: Name: birth date: Name: birth date: American LegalNet, Inc. www.FormsWorkFlow.com