Free Cover Sheet - Indiana

So that the Order of Protection is valid, after you print, YOU MUST REPLACE THIS PAGE with the

Cover Sheet: Order of Protection
(available for download in PDF format)

PO-0123

Approved 07-01-07 Revised 07-01-09

STATE OF INDIANA COUNTY OF ________

) ) SS: )

IN THE ________________COURT____ (_______________ DIVISION, ROOM __) CASE NO._________________________

_______________________, ) Petitioner ) vs. ) _______________________, ) Respondent ) ORDER FOR PROTECTION FINDINGS This matter having been heard by the Court on ____________________ pursuant to Indiana Code § 34-26-5-10, the Court now makes the following Findings (strike through those which do not apply): a. _______________________ filed a timely Request for Hearing pursuant to Indiana Code § 34-26-5-10(a); and/or, b. The Court is required to hold a hearing pursuant to Indiana Code § 34-26-5-10(b). c. The Petitioner was present at the hearing and the Respondent was / was not present. d. This order does / does not protect an intimate partner or child. e. The Respondent had notice and an opportunity to be heard. f. The Respondent represents a credible threat to the safety of the Petitioner or a member of the Petitioner's household. g. The Petitioner has shown, by a preponderance of the evidence, that domestic or family violence, a sex offense or stalking has occurred sufficient to justify the issuance of this Order. h. The Respondent does / does not agree to the issuance of the Order for Protection. i. The following relief is necessary to bring about a cessation of the violence or the threat of violence. ORDER (strike through those which do not apply) General Provisions 1. The Respondent is hereby enjoined from threatening to commit or committing acts of domestic or family violence, stalking and sex offenses against the Petitioner and the following designated family or household members, if any: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________.

IDACS Codes:

01 Petitioner 02- Others

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PO-0123

Approved 07-01-07 Revised 07-01-09

2. The Respondent is prohibited from harassing, annoying, telephoning, contacting, or directly or indirectly communicating with the Petitioner, except:__________ _________________________________________________________________. 3. The Respondent shall be removed and excluded from the Petitioner's residence. 4. The Respondent is ordered to stay away from the residence, ___school, ___and/or place of employment, of the Petitioner. The Respondent is further ordered to stay away from the following place(s) that is/are frequented by the Petitioner and/or the Petitioner's family or household members: _______________________________ __________________________________________________________________. 5. The Petitioner shall have the possession and use of the residence/motor vehicle/other essential personal effects as follows: _________________________________________________________________
_____________________________________________________________________________.

05

03 04 03 ­ Residence 08 - Other 08

6. The Court orders the following additional relief to provide for the safety and welfare of the Petitioner and each family or household member designated in Paragraph 1 of this Order: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________. 7. To law enforcement officers: You are hereby directed to accompany the Petitioner to the residence of the parties to ensure that the Petitioner is safely restored to the possession of the residence/motor vehicle/other essential personal effects listed above; or, you are to supervise the Petitioner's or Respondent's removal of personal belongings. Duration of Order THIS ORDER FOR PROTECTION EXPIRES: ____ TWO (2) YEARS FROM THE DATE IT IS ISSUED; OR ____ ON THE _____ DAY OF __________________, 2____. THE RESPONDENT IS ORDERED TO PAY COURT COSTS TO THE CLERK IN THE AMOUNT OF $_____ UNDER INDIANA CODE § 34-26-5-16. DATE:__________ Recommended for approval by, if applicable: _____________________________________ ____________, COMMISSIONER/REFEREE Approved and ordered by: _____________________________________ ________________, JUDGE/MAGISTRATE

08

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PO-0123

Approved 07-01-07 Revised 07-01-09

******IMPORTANT NOTICE****** VIOLATION OF THIS ORDER IS PUNISHABLE BY CONFINEMENT IN JAIL, PRISON, AND/OR A FINE. IF SO ORDERED BY THE COURT, THE RESPONDENT IS FORBIDDEN TO ENTER OR STAY AT THE PETITIONER'S RESIDENCE OR RESIDENCE OF ANY CHILD WHO IS THE SUBJECT OF THE ORDER, EVEN IF INVITED TO DO SO BY THE PETITIONER OR ANY OTHER PERSON. IN NO EVENT IS THE ORDER FOR PROTECTION VOIDED. PURSUANT TO 18 U.S.C. 2265, THIS ORDER FOR PROTECTION SHALL BE GIVEN FULL FAITH AND CREDIT IN ANY OTHER STATE OR TRIBAL LAND AND SHALL BE ENFORCED AS IF IT WERE AN ORDER ISSUED IN THAT STATE OR TRIBAL LAND. PURSUANT TO 18 U.S.C. 922(g), ONCE A RESPONDENT HAS RECEIVED NOTICE OF THIS ORDER AND AN OPPORTUNITY TO BE HEARD, IT IS A FEDERAL VIOLATION TO PURCHASE, RECEIVE, OR POSSESS A FIREARM WHILE SUBJECT TO THIS ORDER IF THE PROTECTED PERSON IS: (A) THE RESPONDENT'S CURRENT OR FORMER SPOUSE; (B) A CURRENT OR FORMER PERSON WITH WHOM THE RESPONDENT RESIDED WHILE IN AN INTIMATE RELATIONSHIP; OR (C) A PERSON WITH WHOM THE RESPONDENT HAS A CHILD. INTERSTATE VIOLATION OF THIS ORDER MAY SUBJECT THE RESPONDENT TO FEDERAL CRIMINAL PENALTIES UNDER 18 U.S.C. 2261 AND 18 U.S.C. 2262.

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