Case Identification Information For Confidential Form {PO-0104}

CASE IDENTIFICATION INFORMATION FOR CONFIDENTIAL FORM For use by Court, Clerk, Prosecuting Attorney, and Law Enforcement Personnel ONLY DIVISION OF STATE COURT ADMINISTRATION STATE OF INDIANA ) COUNTY OF _________ ) _________________________________________________ PETITIONER/PLAINTIFF/NEXTFRIEND/STATE OF INDIANA COURT: (check one) Superior, Room #: _________ Circuit CASE #: _________-________-_____-_________ DATE: ___________ mm/dd/yyyy v. _________________________________________________ RESPONDENT/DEFENDANT _________________________________________________ EMPLOYEE (IF WVRO) PERSON RESTRAINED Name: Home address: Home: (______) ____________________ Work: (______) ____________________ Cell: (______) ____________________ Email: ________________________________________ Postal address (if different from home address): Location of place of business or where person is usually or often found: Sex: DOB: male female Describe nature and location of any scars or tattoos: Yes Hair color: No Eye Color: Height: Weight: Any scars or tattoos? Race: List the name(s), age, race, and sex of any person(s) residing at the household of the protected person who are NOT PROTECTED parties. Protected parties are listed on the Confidential Form which follows. Attach an additional sheet of paper if necessary. Name: Name: Name: Name: Name: Name: Age: Race: Age: Race: Age: Race: Age: Race: Age: Race: Age: Race: 1 Sex: Sex: Sex: Sex: Sex: Sex: Male Male Male Male Male Male Female Female Female Female Female Female TCM-PO-0104 Approved 07/02 Rev. by State Ct. Admin. 07/12 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL FORM Note: The following information is confidential under Indiana law pursuant to Indiana Code § 5-2-9-7, and it may not be released. PETITIONER Home address: DOB: Race: Sex: SSN: (optional) male female Home: Work: Fax: Cell: Email: (______) ____________________ (______) ____________________ (______) ____________________ (______) ____________________ ________________________________________ PROTECTION ORDERS ONLY: Do you wish to receive notifications when the order is issued, served, and about to expire? Yes No Method: Email Text Fax Cell Phone Service Provider (if you selected Text as the notification method): __________________________ You must provide data in the proper fields above to match the Method of notification chosen. See Notification Information at the bottom of this form. Postal address (if different from home address): 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: ___________________________________________________ ___________________________________________________ ___________________________________________________ Other protected address: Address from confidentiality program of Attorney General: OTHER PROTECTED PARTIES Name: Age: Date of Birth: Age: Date of Birth: Age: Date of Birth: Sex: Race: Sex: Race: Sex: Race: Male Female Name: Name: Male Male Female Female Attach an additional sheet of paper if necessary to list additional protected parties. PERSON RESTRAINED SSN: ___________________________________ The "Confidential Form" portion of this form must be on green paper according to Admin. Rule 9 Notification Information · The user will incur standard text-messaging fees for any messages received. · The user is responsible to notify the Clerk's office of any changes to their contact information which may include their cell phone number and email address. · The Indiana Supreme Court's Division of State Court Administration may not be held liable for the failure of the receipt of a notification. · The notifications sent to users are a service being provided by the Indiana Supreme Court's Division of State Court Administration. · Cell Phone Service Providers Supported: Alltel, AT&T, Boost, Cellular South, Centennial Wireless, Cincinnati Bell, Cricket Wireless, Metro PCS, Powertel, Qwest, Rogers, Sprint, Suncom, Telus, T-Mobile, US Cellular, Verizon Wireless, Virgin Mobile 2 TCM-PO-0104 Approved 07/02 Rev. by State Ct. Admin. 07/12 American LegalNet, Inc. www.FormsWorkFlow.com