WPF DV-1.050-FPOI (12/2001) RCW 26.52.030 - Page 1 of 1 DO NOT SERVE OR SHOW THIS FORM TO THE RESTRAINED PERSON Case No: CONFIDENTIAL FOREIGN PROTECTION ORDER INFORMATION Fill in as much of the following information as possible. Type or print only. PERSON BEING RESTRAINED [ ] Interpreter needed in Name (Last, First, Middle) Nickname Alias Race Ethnicity Sex Height Weight Eye Color Hair Color Skin Tone Build/Physical Description Birthdate Social Security Number Dr. License or Identicard (# and State) Current Street Address (City, State, Zip Code) Home Phone Number Vehicle License No. Vehicle Make and Model Vehicle Color Vehicle Year PERSONS BEING PROTECTED Relation to Person Being Restrained: Name (Last, First, Middle) Driver222s License or Identicard, (# and state) Birthdate Race Sex CHILDREN AND HOUSEHOLD MEMBERS Name (First, Middle Initial, Last) Birthdate Age Race Sex Dr. Lic., or Identicard (# and State) How Related to Persons Protected Restrained Resides with HISTORY/HAZARD INFORMATION HISTORY [ ] Mental Health Problems [ ] Assault [ ] Assault w/Weapons [ ] Alcohol/Drug Abuse WEAPONS [ ] Guns/Rifles [ ] Knives [ ] Explosives [ ] Other Describe in detail: Location of Weapons: [ ] Vehicle [ ] On Person [ ] Residence FOREIGN PROTECTION ORDER INFORMATION Originating court (name, address, telephone number): Originating court cause number: Date Order was entered: Expiration date: Respondent served by: [ ] personal service [ ] certified mail [ ] Respondent attended hearing [ ] other [ ] Other legal proceeding between same individual (type, cause number and location of court): RELIEF GRANTED (Restrained person is prohibited from) [ ] Information regarding relief granted, citations and violations that are arrestable offenses is in the attached order. DO NOT SERVE OR SHOW THIS SHEET TO THE PERSON RESTRAINED/RESPONDENT. COURT CLERKS: GIVE THIS FORM TO LAW ENFORCEMENT. DO NOT FILE IN THE COURT FILE. American LegalNet, Inc. www.FormsWorkFlow.com