JV-125 (Rev. 03/30/2018)
COMPLAINT FOR PROTECTION FROM HARASSMENT
INTAKE FORM
(MUST BE COMPLETED FOR PLAINTIFF AND/OR DEFENDANT WHO
ARE/IS UNDER 18 YEARS OF AGE)
DOCKET NO.
PLAINTIFF DEFENDANT
PLAINTIFF'S NAME DEFENDANT'S NAME
Is Plaintiff Under 17 Years
of age?
Yes No
Date of Birth
Month Day Year
Is Defendant Under 17 Years
of age?
Yes No
Date of Birth
Month Day Year
Parent Information
(Complete if Plaintiff is under 17 years of age)
1. Mother/Parent/Guardian
(First Name) (M.I.) (Last Name)
(Street) (Apt.)
(City) (State) (Zip Code)
(Area Code and Telephone No.)
2. Father/Parent/Guardian
(First Name) (M.I.) (Last Name)
(Street) (Apt.)
(City) (State) (Zip Code)
(Area Code and Telephone No.)
Do not include parent(s)' address if Plaintiff requested to
keep address confidential from the Defendant.
Parent Information
(Complete if Defendant is under 17 years of age)
1. Mother/Parent/Guardian
(First Name) (M.I.) (Last Name)
(Street) (Apt.)
(City) (State) (Zip Code)
(Area Code and Telephone No.)
2. Father/Parent/Guardian
(First Name) (M.I.) (Last Name)
(Street) (Apt.)
(City) (State) (Zip Code)
(Area Code and Telephone No.)
FOR COURT USE ONLY
