Do Not Serve Or Show This Sheet To The Restrained Person Court Clerks: Give this form to Law Enforcement. Do Not File in the court file. Domestic Violence Case Number Dissolution/Separation/Invalidity/Nonparental Custody/Paternity Antiharassment Sexual Assault Law Enforcement Information 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. Type or Print Only. Name of Restrained Person (Last, First, Middle) Restrained Person’s Information Drivers License or ID Number (specify type) Height Weight Eye Color Nickname Hair Color Sex Skin Tone Race Build Relation to Protected Person Home Phone Last Known Address (Street, City, State, Zip) Birth date Interpreter Required? Language: Other Address (Street, City, State, Zip), if any: Employer Employer's Address Vehicle License Number Vehicle Make and Model Vehicle Year Name of Protected Person (Last, First, Middle) Protected Person’s Information Sex: Work Hours: Phone: Vehicle Color Race: Birth date: If your information is not confidential, you must enter your address and phone number(s). Current Address (Street, City, State, Zip) Phone 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 (For SA Orders Only) Name and contact phone number of person filing petition on behalf of protected person: Minor’s Information Minor’s Name (Last, First, Middle) Hazard Information Describe the minor’s relationship using terms such as: child, grandchild, stepchild, nephew, none. à Sex Race Birth date Resides With Weapons Guns/Rifles Knives Explosives Other Minor’s Relationship to Protected Restrained Person Person Location of Weapons: Describe in detail: Vehicle On Person Residence Current Status (For DV Orders Only) (circle) Are you and the restrained person living together right now? Does the restrained person know you are trying to get this order? Does the restrained person know he/she may be moved out of home? Is the restrained person likely to react violently when served? See Reverse for Additional Information Prepared by: Yes Yes Yes Yes No No No No Restrained Person’s History Includes: Mental Health Problems (Commitment, Treatment, Suicide Attempt, Other) Assault Assault With Weapons Alcohol/Drug Abuse Date WPF SA-1.040 LEIS (6/2006) American LegalNet, Inc. www.USCourtForms.com