Form 10-A - Protection Order Notice To Ncic Page 2

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[Page 2 of 2 of Form 10-A]
Subject’s Name____________________________
Case/Order No. __________________________
LIST ALL PROTECTED PERSONS (Total of 9 allowed. SSN is NOT necessary if DOB is given.)
PROTECTED PERSON
(LAST)
(FIRST)
(M.I.)
DOB
/
/
SSN
-
-
RACE
SEX
M
F
PROTECTED PERSON
(LAST)
(FIRST)
(M.I.)
DOB
/
/
SSN
-
-
RACE
SEX
M
F
PROTECTED PERSON
(LAST)
(FIRST)
(M.I.)
DOB
/
/
SSN
-
-
RACE
SEX
M
F
PROTECTED PERSON
(LAST)
(FIRST)
(M.I.)
DOB
/
/
SSN
-
-
RACE
SEX
M
F
PROTECTED PERSON
(LAST)
(FIRST)
(M.I.)
DOB
/
/
SSN
-
-
RACE
SEX
M
F
PROTECTED PERSON
(LAST)
(FIRST)
(M.I.)
DOB
/
/
SSN
-
-
RACE
SEX
M
F
PROTECTED PERSON
(LAST)
(FIRST)
(M.I.)
DOB
/
/
SSN
-
-
RACE
SEX
M
F
PROTECTED PERSON
(LAST)
(FIRST)
(M.I.)
DOB
/
/
SSN
-
-
RACE
SEX
M
F
PROTECTED PERSON
(LAST)
(FIRST)
(M.I.)
DOB
/
/
SSN
-
-
RACE
SEX
M
F
Authorized by (signature):
Date
/
/
Judge/Magistrate (circle one)
i
Print Form
FORM 10-A: PROTECTION NOTICE TO NCIC
Amended: March 1, 2014
Discard all previous versions of this form

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