Fill and Sign the Court Clerks Give This Form to Law Enforcement

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. Case Number Domestic Violence 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 en ter your order into the state wide law enforcement computer. Fill in the following information as completely as possible. Type or print only. Restrained Person’s Information Name of Restrained Pers on (Last, First, Middle) Drivers License or ID Number (specify type) Nickname Sex Race Birth date Height Weight Eye Color Hair Color Skin Tone Build Relation to Protected Person Last Known Address (Street, City, State, Zip) Home Phone Interpreter Required? Language: Other Address (Street, City, State, Zip), if any: Employer Employer's Address WORK Hours: Phone: Vehicle License Number Vehicle Make and Model Vehicle Color Vehicle Year Protected Person’s Information Name of Protected Person (Last, First, Middle) Sex: 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, a ddress 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 Describe the minor’s relationship using terms such as: child, grandchild, stepchild, nephew, none. Æ Minor’s Relationship to Protected Restrained Minor’s Name (Last, First, Middle) Sex Race Birth date Resides With Person Person Hazard Information Weapons Guns/Rifles Knives Explosives Other Location of Weapons: Describe in detail: Vehicle On Person Residence Current Status (For DV Orders Only) (circle ) Restrained Person’s History Includes: Are you and the restrained person living together right now? Yes No Does the restrained person know you are trying to get this order? Yes No Does the restrained person know he/she may be moved out of home? Yes No Is the restrained person likely to react violently when served? Yes No Mental Health Problems (Commitment, Treatment, Suicide Attempt, Other) Assault Assault with Weapons Alcohol/Drug Abuse See Reverse For Additional Information Prepared by: Date WPF DR 04.0180 LEIS (6/2006)