Fill and Sign the Indiana Protective Order Form

NOTICE OF EXTENSION OR MODIFICATION DIVISION OF STATE COURT ADMINISTRATION STATE OF INDIANA ) COUNTY OF ____________) COURT: ______________________________ _____________________________________ CASE #:__________________________________ PETITIONER/PLAINTIFF/STATE OF INDIANA V. _____________________________________ DATE: __________________________ RESPONDENT/DEFENDANT _______________________________________________ EMPLOYEE (IF WVRO) Notice is hereby given that an order previously issued under the provisions of Indiana Code § 5-2-9 has been extended or modified. PERSON PROTECTED Name: ______________________________________________________________________ Birth Year:_______________________ Race: ___________________________Sex: Male [ ] Female [ ] PERSON RESTRAINED Name: ______________________________ Telephone No.: Home:( )______________________ Date of birth:____________________ Work: ( )______________________ Sex: Male [ ] Female [ ] Race:_______________________________ Home Address:___________________________________________________________________________ Location of place of business or where person usually/often found:__________________________________ REASON FOR EXTENSION OR MODIFICATION _____(a.) Extended due to: _______ motion for continuance . Hearing date moved to:_____________(date). Conditions of the order remain unchanged. ______(b.) Modified due to: _________Petitioner’s/Protected Person’s or Respondent’s/Defendant’s change of address ( NOTE: page 3 of this form needs to be completed ONLY WHEN this applies). _________ conditions of the order have been modified. See attached order. _________ other. See attached order. Date order was issued:__________________________________________________________ Date order was modified or extended:_________________________________________________________ Date order will be terminated:_______________________________________________________________ TCM-PO-0117 Approved 07/02 Rev. by State Ct. Admin. 07/10 1 TYPE OF ACTION _____ No Contact Order Juvenile Court [Indiana Code § 31-32-13] _____ Child Protective Order CHINS [Indiana Code § 31-34-2.3] _____ No Contact Order CHINS [Indiana Code § 31-34-20] _____ No Contact Order CHINS [Indiana Code § 31-34-25] _____ No Contact Order Delinquency [Indiana Code § 31-37-19] _____ No Contact Order Delinquency [Indiana Code § 31-37-25] _____ No Contact Order Pretrial Diversion [Indiana Code § 33-39-1-8] _____ Ex Parte Order for Protection [Indiana Code § 34-26-5] _____ Order for Protection Issued After a Hearing [Indiana Code § 34-26-5] _____ Workplace Violence Restraining Order—Temporary Restraining Order [Indiana Code § 34-26-6] _____ Workplace Violence Restraining Order—Injunction [Indiana Code § 34-26-6] _____ No Contact Order Pretrial Release [Indiana Code § 35-33-8-3.2 ] _____ No Contact Order Pretrial Release No Hearing [Indiana Code § 35-38-8-3.6] _____ No Contact Order Executed Sentence/Condition of Probation [Indiana Code § 35-38-1-30/Indiana Code § 35-38-2-2.3]_ Prepared by:______________________________________________________________ Notice to Protected Person/Plaintiff: The address and telephone number listed here will not be kept confidential. The Protected Person/Plaintiff should designate a Public Mailing Address for purposes of serving pleadings, notices, and court orders. Name: ________________________________________________________________________________ Address:________________________________________________________________________________ ________________________________________________________________________________ City: _________________________________________________________________ Telephone:____________________________________ Attorney Number (if applicable): __________________ FOR USE BY CLERK OF COURT NOTICE OF EXTENSION OR MODIFICATION has been sent to the following law enforcement agencies: _______ Sheriff of ______________________________________________ County. _______ Any other sheriff or enforcement agency of a municipality named in the order: Name(s) of county(ies):_____________________________________________________________. Name(s) of municipality(ies):________________________________________________________. TCM-PO-0117 Approved 07/02 Rev. by State Ct. Admin. 07/10 2 NOTE: This portion must be completed when a protection, no-contact, workplace violence restraining order is requested. The information provided on this form will be used to update the statewide protective order database for the enforcement of the order. CONFIDENTIAL FORM Note: The following information is confidential under Indiana law pursuant to Indiana Code § 5-2-9-7, and it may not be released. PETITIONER Home address: DOB: Race: Sex: male female SSN: (optional) Home: (______)_____________________ Work: (______)_____________________ Cell: (______)_____________________ Email: __________________________________________ Postal address (if different from home address): When can protected person be reached at the above numbers or any alternative numbers? List the cities/counties where the protected person would like a copy of the order sent: _____________________________________________________ _____________________________________________________ _______________________________________________Other protected address: Address from confidentiality program of Attorney General: PERSON RESTRAINED SSN: ___________________________________ TCM-PO-0117 Approved 07/02 Rev. by State Ct. Admin. 07/10 3End of Confidential Form. The “Confidential Form” portion of this form must be on green paper according to Admin. Rule 9