Fill and Sign the Law Enforcement Do Not Serve or Show This Sheet to the Form

WPF A ll C ase s 0 1.0 400 L E IS ( 6 /2 010 ) See Reverse For Additional Information  LAW ENFORCEMENT INFORMATIONDo NOT serve or show this sheet to the restrained person! 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. Cou rt:C ase N um ber: D om estic V io le nce D is so lu tio n/S epara tio n/In va lid it y /N onpare nta l C usto dy/P ate rn it y U nla w fu l H ara ssm ent Vulnerable Adult Sexual Assault Restrained Person’s Information (This is the person that you want the court to restrain.)Name: First Middle LastNicknameRelationship to Protected Person Date of Birth Male Female RaceHeightWeightEye ColorHair ColorSkin Tone Build Last Known AddressStreet:City: State: Zip:Phone(s) w/Area CodeNeed Interpreter? Yes or NoLanguage: Employer Employer's Address WORK Hours:Phone: ( )Vehicle License NumberVehicle Make and ModelVehicle ColorVehicle YearDrivers License or ID numberState 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 NAre 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/ADoes the restrained person know you’re trying to get this order? Y N Is the restrained person likely to react violently when served? Y NProtected Person’s Information (This is the person you want the court to protect.)Name: First Middle Last Date of Birth Male Female RaceHeightWeightEye ColorHair ColorSkin Tone Build If your information is not confidential, you must enter your address and phone number(s).Current AddressStreet: City: State: Zip:Phone(s) w/Area CodeNeed interpreter? Yes or No Language: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 numberand address: Minor’s Information Describe the minor’s relationship using terms suchas: child, grandchild, stepchild, nephew, none.  Minor’s Relationship to Protected RestrainedName: First Middle LastSex RaceBirth date Resides WithPerson PersonVictim’s Household Members or Adult Children Protected Name: birth date:Name: birth date:Name: birth date: