Free Notice to Indiana State Police Re - Indiana

PO-0104

Approved 07-01-02 Revised 07-01-08

CONFIDENTIAL FORM
For use by Court, Clerk, Prosecuting Attorney, and Law Enforcement Personnel ONLY

DIVISION OF STATE COURT ADMINISTRATION Note:
The following information is confidential under Indiana law pursuant to Indiana Code § 5-2-9-7, and it may not be released.

STATE OF INDIANA

)

COURT: (check one)

Superior, Room #: _________ Circuit

COUNTY OF _________ ) _______________________________________________
PETITIONER/PLAINTIFF/STATE OF INDIANA

CASE #: _________-________-_____-_________ DATE: ___________ m/d/yyyy

v. _______________________________________________
RESPONDENT/DEFENDANT

_______________________________________________
EMPLOYEE (IF WVRO)

Name: Home address:

PERSON PROTECTED Does the protected person live within a municipal boundary? Yes No (i.e., within city/town limits) If yes, which municipality? ______________________

SSN: (optional) DOB: Race: male female Sex: Postal address (if different from home address):

Telephone No.: Home: (______)___________________ Work: (______)___________________ 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: ___________________________________________________ ___________________________________________________ ___________________________________________________ PERSON RESTRAINED Telephone No.: Home: (______)___________________ Work: (______)___________________

Other protected address:

Name: Home address:

Postal address (if different from home address):

Location of place of business or where person is usually or often found:

Sex: DOB:

male

female SSN: Yes Hair color: No

Describe nature and location of any scars or tattoos:

Any scars or tattoos? Race:

Height:

Weight:

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PO-0104

Approved 07-01-02 Revised 07-01-08

List the name(s), dates of birth [DOB], race, and sex of any person(s) residing at the household of the protected person. Attach an additional sheet of paper if necessary. Name: DOB: Race: DOB: Race: DOB: Race: DOB: Race: DOB: Race: DOB: Race: DOB: Race: DOB: Race: Sex: Male Female

Name:

Sex:

Male

Female

Name: Name:

Sex:

Male

Female

Sex:

Male

Female

Name:

Sex:

Male

Female

Name:

Sex:

Male

Female

Name:

Sex:

Male

Female

Name:

Sex:

Male

Female

NOTE: This portion of the Confidential Form must be completed when an order for protection, no-contact order, or 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.

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