Tcm-Po-0104 Case Identification Information For Confidential Form Page 2
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2CONFIDENTIAL 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:
SSN: (optional)
Home: (______) ____________________
Race:
Work: (______) ____________________
Sex:
male
female
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?
Other protected address:
List the cities/counties where the protected person would like a
copy of the order sent:
___________________________________________________
Address from confidentiality program of Attorney General:
___________________________________________________
___________________________________________________
OTHER PROTECTED PARTIES
Name:
Age:
Sex:
Male
Female
Date of Birth:
Race:
Name:
Age:
Sex:
Male
Female
Date of Birth:
Race:
Name:
Age:
Sex:
Male
Female
Date of Birth:
Race:
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
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TCM-PO-0104
Approved 07/02
Rev. by State Ct. Admin. 07/12
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