Law Enforcement Service Information Sheet

C O N F I D E N T I A L

Law Enforcement Service Information Sheet for DOMESTIC VIOLENCE PROTECTION ORDERS

Information About You:

Last Name:			First:					Middle Initial:
Date of Birth:	Race:		[ ] Male [ ] Female			Social Security No.
Present Address:			City:		State:		ZIP:
Home Phone No.:		Another Phone No. Where Message Can Be Left:
Where You Work:				Work Phone No.:
Relative/Friend Not Living With You:				Their Phone No.:

Information About Person Who Abused You: (If you are seeking a domestic violence protection order against more than one person, fill out this portion for each person.)

Last Name:			First:					Middle Initial:
Date of Birth:	Race:		[ ] Male [ ] Female			Social Security No.
Present Address:			City:		State:		ZIP:
Home Phone No.:		Another Phone No. Where Message Can Be Left:
Employer/Company Name:				Work Phone No.:
Business Address:			City:		State:		ZIP:
Work Days/Hours:
Name of Relative or Friend:				Their Phone No.:
Make & Model of Car:				Color:				Year:
License Plate No.:				State of License Plate:

What Does This Person Look Like?

Height:	Weight:	Hair Color:	Eye Color:
Describe Any Scars or Tattoos:

Additional Important Information:

Has this person been convicted of a crime? [ ] Yes [ ] No	If yes, for what?
Do you consider this person dangerous? [ ] Yes [ ] No	Does this person have any weapons? [ ] Yes [ ] No
Places Where This Person Can Be Found: