Fill and Sign the Law Enforcement Information Sheet

LAW ENFORCEMENT INFORMATION Do 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. Court: Case Number: Domestic Violence Dissolution/Separation/Invalidity/Nonparental Custody/Paternity Unlawful Harassment Vulnerable Adult Sexual Assault Restrained Person’s Information (This is the person that you want the court to restrain.) Name: First Middle Last Nickname Relationship to Protected Person Date of Birth Male Female Race Height Weight Eye Color Hair Color Skin Tone Build Last Known Address Street: City: State: Zip: Phone(s) w/Area Code Need Interpreter? Yes or No Language: Employer Employer's Address WORK Hours: Phone: ( ) Vehicle License Number Vehicle Make and Model Vehicle Color Vehicle Year 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 Y es, N o 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: First Middle Last Date of Birth Male Female Race Height Weight Eye Color Hair Color Skin Tone Build If your information is not confidential , you must enter your address and phone number(s). Current Address Street: City: State: Zip: Phone(s) w/Area Code Need 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 number and address: Minor’s Information Describe the minor’s relationship using terms such as: child, grandchild, stepchild, nephew, none.  Minor’s Relationship to Protected Restrained Name : First Middle Last Sex Race Birth date Resides With Person Person Victim’s Household Members or Adult Children Protected Name: birth date: Name: birth date: Name: birth date: WPF All Cases 01.0400 LEIS (6/2010) See Reverse For Additional Information 