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)

WV-0106

Approved 07-01-02 Revised 07-01-09

STATE OF INDIANA

) )SS: COUNTY OF ____________)

IN THE __________________COURT___ (_______________DIVISION, ROOM___) CASE NO.__________________________

PLAINTIFF: ___________________________________________ DEFENDANT: _________________________________________ EMPLOYEE: __________________________________________ ORDER AFTER HEARING ON PETITION OF EMPLOYER FOR INJUNCTION PROHIBITING VIOLENCE OR THREATS OF VIOLENCE AGAINST EMPLOYEE 1. 2. THIS ORDER SHALL EXPIRE AT MIDNIGHT ON (date): _________________________________________. This proceeding came on for hearing as follows: a. Date: _______________________ b. Time: _______________________ c. Court/Room No. ___________________________________ d. Judge: _______________________________________________ a. __ Plaintiff present __ Attorney present (name): ________________________ b. __ Defendant present __Attorney present (name): ______________________

3.

THE COURT FINDS 4. a. The defendant is (name): _____________________________________ Sex: ___ Male __ Female Ht.: _____ Wt.: _____ Hair color: __________ Eye color: __________ Age: _________ Race: __________________________ Date of birth: __________________ b. c. The protected employee is (name): _______________________________ Protected family or household members who reside with employee are: (1) (Name): ______________________________________________ Sex: __ Male __ Female Date of birth: __________________________ (2) (Name): ______________________________________________ Sex: __ Male __ Female Date of birth: __________________________ (3) (Name): ______________________________________________ Sex: __ Male __ Female Date of birth: __________________________ __ Continued on Attachment 4c.

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WV-0106

Approved 07-01-02 Revised 07-01-09

d.

The plaintiff has shown by clear and convincing evidence that the defendant engaged in unlawful violence or made a credible threat of violence.

THE COURT ORDERS 5. Defendant is prohibited from further violence or threats of violence against employee (name): _______________________________ and SPECIFICALLY DEFENDANT a. __ shall not batter or stalk the employee and other protected persons b. __ shall not follow or stalk the employee and other protected persons to or from the place of work c. __ shall not follow the employee and other protected persons during hours of employment d. __ shall not telephone or send correspondence to the employee and other protected persons by any means including, but not limited to, the use of the public or private mails, interoffice mail, fax, or computer e-mail e. __ shall not enter the workplace of the employee and other protected persons f. __ other (specify): ____________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ a. (1) (2) (3) (4) (5) Defendant is ordered to stay at least (specify): _____ yards away from the following persons and places (the addresses of the places are optional and may be kept confidential): __ Employee (name): _________________ _________________________________________________________ __ Employee's residence (address optional): _________________________________________________________ __ Employee's place of work (address optional): _________________________________________________________ __ Employee's children's school or place of child care (address optional): _________________________________________________________ _________________________________________________________ __ Other (specify): __________________________________________ _________________________________________________________ (address optional): __________________________________________ __________________________________________________________ __ Contacts relating to pickup and delivery of children pursuant to a court order or a court approved agreement of the parties shall be permitted, unless a no-contact order or an order for protection prohibits such contacts.

6.

b.

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WV-0106

Approved 07-01-02 Revised 07-01-09

7.

8.

__ OTHER ORDERS (specify): ________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ By the close of business on the date of this order, a copy of this order and any proof of service shall be given to the law enforcement agencies listed below as follows: a. __ Plaintiff shall deliver. b. __ Plaintiff's attorney shall deliver. Law enforcement agency Address ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Date: _________________ ____________________________ JUDGE

******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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