Include the following notice if the document is filed with the court. See § 6 of the Introduction in volume 1 of this manual concerning protection of sensitive data in filed documents.

CAUSE NO:

[number] JUDICIAL COURT

APPLICANT:

Name:

Address:

City/State/ZIP Code:

RESPONDENT:

Name:

Address:

City/State/ZIP Code:

SPN:

SCHOOL/DAYCARE:

Name:

Address:

City/State/ZIP Code:

MANDATORY MILITARY INFORMATION:

Is Respondent a member of the state military forces or currently serving in the armed forces of the United States in an active duty status?         [Yes/No]

If “Yes,” state the mailing address of the staff judge advocate at Joint Force Headquarters or the provost marshal of the military installation Respondent is currently assigned to, as applicable, and the name of the commanding officer: