Notice of extension or modification




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NOTICE OF EXTENSION OR MODIFICATION

DIVISION OF STATE COURT ADMINISTRATION


STATE OF INDIANA )

COUNTY OF ____________) COURT: ______________________________
_____________________________________ CASE #:__________________________________

PETITIONER/PLAINTIFF/STATE OF INDIANA

V.

_____________________________________ DATE: __________________________

RESPONDENT/DEFENDANT
_______________________________________________

EMPLOYEE (IF WVRO)
Notice is hereby given that an order previously issued under the provisions of Indiana Code § 5-2-9 has been extended or modified.

PERSON PROTECTED

Name: ______________________________________________________________________

Birth Year:_______________________ Race: ___________________________Sex: Male [ ] Female [ ]


PERSON RESTRAINED

Name: ______________________________ Telephone No.: Home:( )______________________

Date of birth:____________________ Work: ( )______________________

Sex: Male [ ] Female [ ] Race:_______________________________

Home Address:___________________________________________________________________________

Location of place of business or where person usually/often found:__________________________________




REASON FOR EXTENSION OR MODIFICATION

_____(a.) Extended due to:

_______ motion for continuance. Hearing date moved to:_____________(date).

Conditions of the order remain unchanged.





______(b.) Modified due to:

_________Petitioner’s/Protected Person’s or Respondent’s/Defendant’s change of address (NOTE:

page 3 of this form needs to be completed ONLY WHEN this applies).

_________ conditions of the order have been modified. See attached order.

_________other. See attached order.


Date order was issued:__________________________________________________________

Date order was modified or extended:_________________________________________________________

Date order will be terminated:_______________________________________________________________



TYPE OF ACTION

_____ No Contact Order Juvenile Court [Indiana Code § 31-32-13]

_____ Child Protective Order CHINS [Indiana Code § 31-34-2.3]

_____ No Contact Order CHINS [Indiana Code § 31-34-20]

_____ No Contact Order CHINS [Indiana Code § 31-34-25]

_____ No Contact Order Delinquency [Indiana Code § 31-37-19]

_____ No Contact Order Delinquency [Indiana Code § 31-37-25]

_____ No Contact Order Pretrial Diversion [Indiana Code § 33-39-1-8]

_____ Ex Parte Order for Protection [Indiana Code § 34-26-5]

_____ Order for Protection Issued After a Hearing [Indiana Code § 34-26-5]

_____ Workplace Violence Restraining Order—Temporary Restraining Order [Indiana Code § 34-26-6]

_____ Workplace Violence Restraining Order—Injunction [Indiana Code § 34-26-6]

_____ No Contact Order Pretrial Release [Indiana Code § 35-33-8-3.2 ]

_____ No Contact Order Pretrial Release No Hearing [Indiana Code § 35-38-8-3.6]

_____ No Contact Order Executed Sentence/Condition of Probation [Indiana Code § 35-38-1-30/Indiana

Code § 35-38-2-2.3]_


Prepared by:______________________________________________________________





Notice to Protected Person/Plaintiff: The address and telephone number listed here will not be kept confidential. The Protected Person/Plaintiff should designate a Public Mailing Address for purposes of serving pleadings, notices, and court orders.

Name: ________________________________________________________________________________

Address:________________________________________________________________________________

________________________________________________________________________________

City: _________________________________________________________________

Telephone:____________________________________

Attorney Number (if applicable): __________________





FOR USE BY CLERK OF COURT


NOTICE OF EXTENSION OR MODIFICATION has been sent to the following law enforcement agencies:

_______ Sheriff of ______________________________________________ County.

_______ Any other sheriff or enforcement agency of a municipality named in the order:

Name(s) of county(ies):_____________________________________________________________.

Name(s) of municipality(ies):________________________________________________________.









NOTE: This portion must be completed when a protection, no-contact, 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.

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:  male  female

SSN: (optional)

Home: (______)_____________________

Work: (______)_____________________

Cell: (______)_____________________

Email: __________________________________________



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:





PERSON RESTRAINED

S
End of Confidential Form. The “Confidential Form” portion of this form must be on green paper according to Admin. Rule 9
SN: ___________________________________




TCM-PO-0117 Approved 07/02

Rev. by State Ct. Admin. 07/10




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