Free RESPONDENT'S VERIFIED REQUEST FOR A HEARING - Indiana

PO-0107

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

STATE OF INDIANA

) ) SS: COUNTY OF ___________ )

IN THE ________________COURT ____ (_____________ DIVISION, ROOM ____) CASE NO._________________________

_______________________, ) Petitioner ) vs. ) _______________________, ) Respondent (Your Name) )

RESPONDENT'S VERIFIED REQUEST FOR A HEARING

On ________________________, this Court issued (strike through the language that does not apply) an Ex Parte Order for Protection/an Ex Parte Modification of an Order for Protection. I, the undersigned Respondent, received a copy of the Order on ____________________________. Comes now the Respondent, within thirty (30) days of receipt of service of the Order, and pursuant to Indiana Code § 34-26-5-10(a) requests that the Court hold a hearing on the issues in this case. The address and daytime telephone number I wish the Court and opposing party to use in order to contact me about this case is as follows: ___________________________________________________ ______________________________________________________________________. I affirm, under the penalties for perjury, that the foregoing representations are true. DATE: ________ (Respondent's Signature)__________________________ (Printed) __________________________