NCIC Notice Fillable Form

Top case or order number Initial NCIC form Modification of previous form Subject last name Subject first name Subject middle initial Subject street address Subject city Subject state Subject zip Subject height Subject weight Subject hair color Subject eye color Subject race

Subject sex

Subject sex Male Subject sex Female

Subject Social Security Number first part Subject Social Security Number second part Subject Social Security Number third part Subject date of birth month Subject date of birth day Subject date of birth year Driver license number Driver license state Driver license expiration year Vehicle license number Vehicle license state Vehicle license expiration year

Does the Order protect an intimate partner or child(ren)?

Does the Order protect an intimate partner or child(ren)? Yes Does the Order protect an intimate partner or child(ren)? No

Did the subject have an opportunity to participate in the hearing regarding the Order?

Did the subject have an opportunity to participate in the hearing regarding the Order? Yes Did the subject have an opportunity to participate in the hearing regarding the Order? No

Does the Order find the subject a credible threat or explicitly prohibit physical force?

Does the Order find the subject a credible threat or explicitly prohibit physical force? Yes Does the Order find the subject a credible threat or explicitly prohibit physical force? No

Case or order number Court originating agency identifier R.C. 2903.213 R.C. 2903.214 R.C. 2151.34 R.C. 2919.26 R.C. 3113.31 Name of judge or magistrate Date of order month Date of order day Date of order year Expiration of order month Expiration of order day Expiration of order year Term 1 Term 2 Term 3 Term 4 Term 5 Term 6 Term 7 Term 8 Miscellaneous comments line 1 Miscellaneous comments line 2 Miscellaneous comments line 3 Term 9

Subject name Case or order number Protected person 1 last name Protected person 1 first name Protected person 1 middle initial Protected person 1 date of birth month Protected person 1 date of birth day Protected person 1 date of birth year

Protected person 1 sex

Protected person 1 sex Male Protected person 1 sex Female

Protected person 1 Social Security Number first part Protected person 1 Social Security Number second part Protected person 1 Social Security Number third part Protected person 1 race Protected person 2 last name Protected person 2 first name Protected person 2 middle initial Protected person 2 date of birth month Protected person 2 date of birth day Protected person 2 date of birth year

Protected person 2 sex

Protected person 2 sex Male Protected person 2 sex Female

Protected person 2 Social Security Number first part Protected person 2 Social Security Number second part Protected person 2 Social Security Number third part Protected person 2 race Protected person 3 last name Protected person 3 first name Protected person 3 middle initial Protected person 3 date of birth month Protected person 3 date of birth day Protected person 3 date of birth year

Protected person 3 sex

Protected person 3 sex Male Protected person 3 sex Female

Protected person 3 Social Security Number first part Protected person 3 Social Security Number second part Protected person 3 Social Security Number third part Protected person 3 race Protected person 4 last name Protected person 4 first name Protected person 4 middle initial Protected person 4 date of birth month Protected person 4 date of birth day Protected person 4 date of birth year

Protected person 4 sex

Protected person 4 sex Male Protected person 4 sex Female

Protected person 4 Social Security Number first part Protected person 4 Social Security Number second part Protected person 4 Social Security Number third part Protected person 4 race Protected person 5 last name Protected person 5 first name Protected person 5 middle initial Protected person 5 date of birth month Protected person 5 date of birth day Protected person 5 date of birth year

Protected person 5 sex

Protected person 5 sex Male Protected person 5 sex Female

Protected person 5 Social Security Number first part Protected person 5 Social Security Number second part Protected person 5 Social Security Number third part Protected person 5 race Protected person 6 last name Protected person 6 first name Protected person 6 middle initial Protected person 6 date of birth month Protected person 6 date of birth day Protected person 6 date of birth year

Protected person 6 sex

Protected person 6 sex Male Protected person 6 sex Female

Protected person 6 Social Security Number first part Protected person 6 Social Security Number second part Protected person 6 Social Security Number third part Protected person 6 race Protected person 7 last name Protected person 7 first name Protected person 7 middle initial Protected person 7 date of birth month Protected person 7 date of birth day Protected person 7 date of birth year

Protected person 7 sex

Protected person 7 sex Male Protected person 7 sex Female

Protected person 7 Social Security Number first part Protected person 7 Social Security Number second part Protected person 7 Social Security Number third part Protected person 7 race Protected person 8 last name Protected person 8 first name Protected person 8 middle initial Protected person 8 date of birth month Protected person 8 date of birth day Protected person 8 date of birth year

Protected person 8 sex

Protected person 8 sex Male Protected person 8 sex Female

Protected person 8 Social Security Number first part Protected person 8 Social Security Number second part Protected person 8 Social Security Number third part Protected person 8 race Protected person 9 last name Protected person 9 first name Protected person 9 middle initial Protected person 9 date of birth month Protected person 9 date of birth day Protected person 9 date of birth year

Protected person 9 sex

Protected person 9 sex Male Protected person 9 sex Female

Protected person 9 Social Security Number first part Protected person 9 Social Security Number second part Protected person 9 Social Security Number third part Protected person 9 race Authorization date month Authorization date day Authorization date year