FantasticSearch

(g) Indications regarding the prohibition(s) or restriction(s) that have been imposed by the protection measure on the person causing danger:

— Nature of the prohibition(s) or restriction(s): (more than one box may be ticked): a prohibition from entering certain localities, places or defined areas where the protected person resides or visits;

— if you ticked this box, please indicate precisely which localities, places or defined areas the person causing danger is prohibited from entering: a prohibition or regulation of contact, in any form, with the protected person, including by phone, electronic or ordinary mail, fax or any other means;

— if you ticked this box, please provide any relevant details: a prohibition or regulation on approaching the protected person closer than a prescribed distance;

— if you ticked this box, please indicate precisely the distance which the person causing danger has to observe in respect of the protected person:

— Please indicate the length of time during which the abovementioned prohibition(s) or restriction(s) are imposed on the person causing danger:

— Indication of the penalty (if any) in the event of the breach of the prohibition or restriction:

(h) Information regarding the person causing danger on whom the prohibition(s) or restriction(s) mentioned under (g) have been imposed: Surname: Forename(s): Maiden or previous name, where applicable: Aliases, where applicable: Sex: Nationality: Identity number or social security number (if any): Date of birth: Place of birth: Addresses/residences:

— in the issuing State:

— in the executing State:

— elsewhere: Language(s) understood (if known): If available, please provide the following information:

— Type and number of the identity document(s) of the person (ID card, passport): Has the person causing danger been granted free legal aid in the issuing State (if information is available without further enquiry)? Yes. No. Unknown.

(i) Other circumstances that could have an influence on the assessment of the danger that could affect the protected person (optional information):

(j) Other useful information (such as, where available and necessary, information on other States where protection measures have been previously adopted with respect to the same protected person):

(k) Please complete: a judgment within the meaning of Article 2 of Framework Decision 2008/947/JHA, has already been transmitted to another Member State — If you ticked this box, please provide the contact details of the competent authority to whom the judgment has been forwarded: a decision on supervision measures within the meaning of Article 4 of Framework Decision 2009/829/JHA has already been transmitted to another Member State — If you ticked this box, please provide the contact details of the competent authority to whom the decision on supervision measures has been forwarded: Signature of the authority issuing the European protection order and/or of its representative to confirm the accuracy of the content of the order: Name: Position (title/grade): Date: File reference (if any): (Where appropriate) Official stamp:

EUROPEAN PROTECTION ORDER referred to in Article 7 of DIRECTIVE 2011/99/EU OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL OF 13 DECEMBER 2011 ON THE EUROPEAN PROTECTION ORDER The information contained in this form is to be treated with appropriate confidentiality Issuing State: Executing State:

(a) Information regarding the protected person: Surname: Forename(s): Maiden or previous name, where applicable: Sex: Nationality: Identity number or social security number (if any): Date of birth: Place of birth: Addresses/residences:

— in the issuing State:

— in the executing State:

— elsewhere: Language(s) understood (if known): Has the protected person been granted free legal aid in the issuing State (if information is available without further enquiry)? Yes. No. Unknown. Where the protected person is a minor or is legally incapacitated, information regarding the person’s guardian or representative: Surname: Forename(s): Maiden name or previous name, where applicable: Sex: Nationality: Office/Address:

(b) The protected person has decided to reside or already resides in the executing State, or has decided to stay or already stays in the executing State. Date from which the protected person intends to reside or stay in the executing State (if known): Period(s) of stay (if known):

(c) Have any technical devices been provided to the protected person or to the person causing danger to enforce the protection measure: Yes; please give a short summary of the devices used: No.

(d) Competent authority which issued the European protection order: Official name: Full address: Tel. No (country code) (area/city code) (number): Fax No (country code) (area/city code) (number): Details of the person(s) to be contacted Surname: Forename(s): Position (title/grade): Tel. No (country code) (area/city code) (number): Fax No (country code) (area/city code) (number): E-mail (if any): Languages that may be used for communication:

(e) Identification of the protection measure on the basis of which the European protection order has been issued: The protection measure was adopted on (date: DD-MM-YYYY): The protection measure became enforceable on (date: DD-MM-YYYY): File reference of the protection measure (if available): Authority that adopted the protection measure:

(f) Summary of the facts and description of the circumstances — including, where applicable, the classification of the offence — which have led to the imposition of the protection measure mentioned under (e) above: