FA/HA-5 (05/10)
DEFENDANT INFORMATION FORM
AS PROVIDED BY PLAINTIFF
G.L. c. 209A or G.L. c. 258E
DOCKET NO. (for court use only)
Massachusetts Trial Court
This information is requested to help police to identify and locate the Defendant in order to serve the Defendant with a copy of any restraining
Order that is issued. Please provide as much infomation as possible.
DEFENDANT'S NAME DATE OF BIRTH
OTHER NAMES USED BY DEFENDANT, IF ANY PLACE OF BIRTH
MOTHER'S MAIDEN NAME (FIRST & LAST) FATHER'S NAME (FIRST & LAST) SOCIAL SECURITY NO.
SEX
MALE
FEMALE
RACE EYES HAIR HEIGHT WEIGHT
PHOTO AVAILABLE? (very helpful for ID)
YES NO
BUILD
OTHER PHYSICAL CHARACTERISTICS (beard, glasses, scars, tattoos, complexion, hairstyle)
DEFENDANT'S HOME TELEPHONE NO.
APT. NO. FLOOR NO. NAME ON DOOR/MAILBOX DOES DEFENDANT UNDERSTAND ENGLISH? YES NO
IF NOT, WHAT LANGUAGE(S)?
DEFENDANT'S EMPLOYER/WORKPLACE
WORK TELEPHONE NO.
DEPARTMENT
TITLE
WORK ADDRESS (NO., STREET, CITY, STATE, ZIP)
WORK HOURS
OTHER PLACES DEFENDANT MAY BE FOUND (friends, bars, relatives, hangouts)
BEST PLACE TO FIND DEFENDANT
BEST TIMES TO FIND DEFENDANT
COLORMODELMAKEYEARMOTOR VEHICLE LICENSE PLATE
DOES DEFENDANT HAVE: (describe very briefly)
A history of violence toward police officers? NO YES
A history of using/abusing drugs or alcohol? NO YES What kind?
Access to guns, a license to carry, or possess a gun? NO YES What kind?
Psychiatric/emotional problems? NO YES What kind?
ANY OTHER INFORMATION WHICH MIGHT BE HELPFUL IN LOCATING THE DEFENDANT
DATE SIGNED PRINT PLAINTIFF'S NAME PLAINTIFF'S SIGNATURE
X
DEFENDANT'S HOME ADDRESS (NO., STREET, CITY, STATE, ZIP)
