Do NOT FILE in the court file. Give this form to law enforcement. Type or print clearly! This completed form is required by law enforcement. This information is necessary to serve, enforce and enter your order into the state wide law enforcement computer. Fill in the following information as completely as possible. Court: Domestic Violence Unlawful Harassment Case Number: Dissolution/Separation/Invalidity/Nonparental Custody/Paternity Vulnerable Adult Sexual Assault Nickname Eye Color Relationship to Protected Person Skin Tone Build LAW ENFORCEMENT INFORMATION Do NOT serve or show this sheet to the restrained person! Restrained Person's Information (This is the person that you want the court to restrain.) Name: Date of Birth Last Known Address Street: City: Employer First Male Female Middle Race Height Last Weight Hair Color Phone(s) w/Area Code State: Zip: Employer's Address Need Interpreter? Yes or No Language: Vehicle License Number Vehicle Make and Model Vehicle Color Vehicle Year WORK Hours: Phone: ( ) Drivers License or ID number State Does the restrained person have a disability, brain injury, or impairment requiring special assistance when law enforcement serves the order? No Yes. If yes, describe (continue on back, if needed): Hazard Information Restrained Person's History Includes: Involuntary/Voluntary Commitment Suicide Attempt or Threats Assault Assault with Weapons Alcohol/Drug Abuse Other: Weapons: Handguns Rifles Knives Explosives Other: Location of Weapons: Vehicle On Person Residence Describe in detail: Current Status (Circle Yes, No or N/A.) Is 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 know you're trying to get this order? Y N Is the restrained person likely to react violently when served? Y N Protected Person's Information (This is the person you want the court to protect.) Name: Date of Birth First Middle Last Hair Color Skin Tone Build Race Height Weight Eye Color Male Female If your information is not confidential, you must enter your address and phone number(s). Current Address Phone(s) w/Area Code Need interpreter? Yes or No Language: Street: State: Zip: City: If your information is confidential, you must provide the name, address and phone number of someone willing to be your "contact." Contact Name Contact Address Contact Phone If you filed for someone else, list your name, phone number and address: Minor's Information Name: First Middle Last Describe the minor's relationship using terms such as: child, grandchild, stepchild, nephew, none. Sex Race Birth date Resides With Minor's Relationship to Protected Restrained Person Person Victim's Household Members or Adult Children Protected Name: birth date: Name: Name: birth date: birth date: See Reverse For Additional Information American LegalNet, Inc. www.FormsWorkFlow.com WPF All Cases 01.0400 LEIS (6/2010) WPF All Cases 01.0400 LEIS (6/2010) See Reverse For Additional Information American LegalNet, Inc. www.FormsWorkFlow.com