Fill and Sign the Petitionerplaintiffstate of Indiana Form

1 TCM-PO-0118 Approved 07/02 Rev. by State Ct. Admin. 07/10 NOTICE OF TERMINATION STATE OF INDIANA COUNTY OF ________________________________ COURT:________________________________ _________________________________________ PETITIONER/PLAINTIFF/STATE OF INDIANA VS. CASE NO:______________________________ _________________________________________ RESPONDENT/DEFENDANT _________________________________________ EMPLOYEE (IF WVRO) DATE:______________________________ Notice is hereby given that an order previously issued under the provisions of Indiana Code § 5-2- 9 has been terminated. PETITIONER/PROTECTED PERSON Name:_______________________________________________________________________ Birth Year:_________________Race:_________________________Sex: Male [ ] Female [ ] RESPONDENT/DEFENDANT Name:________________________________ Telephone No.: Home:__________________________ Date of Birth:__________________________ Work:__________________________ Sex: Male [ ] Female [ ] Race:________________________________________ Address:________________________________________________________________________________ Location of place of business or where person usually/often found: _________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ REASONS FOR TERMINATION _____ Expiration of Order; _____ The case was a criminal case and the case was dismissed (Motion to Dismiss and Order must be attached); _____ Termination of action by request of the Petitioner/Plaintiff (If a Protective Order case, a copy of the Verified Request for Dismissal and Order must be attached); _____ Court Order (Order must be attached); _____ Protective Order hearing held, Ex Parte Order for Protection has been terminated, and new Protective Order is being issued. _____ WVRO hearing held, TRO has been terminated, and an Injunction is being issued. Date Order of Protection/No-Contact Order/Workplace Violence Restraining Order was issued:________________________________________________ Date Order will terminate:_________________________________________________________ 2 TCM-PO-0118 Approved 07/02 Rev. by State Ct. Admin. 07/10 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 Contac t 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 TERMINATION 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):________________________________________________________.