The following information is needed that your protection order can be entered into the statewide registry of protection orders. If you do not know an answer, leave it blank.

Abuser's name: ___ Abuser's sex: M F Address: ___ Date of birth: ___ Soc.Sec.No.: ___

Abuser's operator's license no.: _____ State: _____ Year: _____

Vehicle registration no.: ___ State: ___ Year: ___ Type: ___

Abuser's place of birth: ___ Height: ___ Weight: ___

Describe any scars, marks, or tatto underset · os: _____

Eye color: ___ Hair color: ___ Skin tone: ___

VICTIM/PLAINTIFF INFORMATION

Name: ___ Date of birth: ___

Address: ___ Your sex: M ___ F ___

Your race:

— American Indian/Alaskan Native — Black

___ Asian/Pacific Islander

___ White

___ Hispanic

- ___ Unknown

IF YOU ARE SEEKING A PROTECTION ORDER FOR ANOTHER PERSON (SUCH AS A

CHILD), PLEASE GIVE THE FOLLOWING INFORMATION FOR THAT PERSON

Person's name: _____ Date of birth: _____

Date of birth: ___

Address: ___

Sex: M__F__

Sex: M__F__

Person's race: American Indian/Alaskan Native

— American Indian/Alaskan Native — Black

Asian/Pacific Islanders

___ White

___ Hispanic

___ Unknown

Last Updated November 22, 2005