russ = Approved ee Revised 07-01-05, STATE OF INDIANA ) IN THE __ COURT ) SS: Cc. ___ DIVISION, ROOM) COUNTYOF i) CASE NO. . ——_________) Petitioner ) vs. ) —— ~ Respondent ) _ __» I, the Petitioner, filed a Petition for an Order for a Hearing, for Protection and Reque: Check appropriate paragraph: At this time, I am requesting this Verified Request for Dismissal pursuant to IC 34- 265-12. [respectfully request that the Court grant this Request without delay or any conditions, and dismiss the case without prejudice. At this time, Lam filing this Verified Request for Dismissal for an Order of Protection to terminate an Order of Protection issued on __ I affirm, under the penalties for perjury, that the foregoing representations are true. DATE: Petitioner’s Signature _ _ __ Printed Pelitioner’s Address __ Respondent’s Address __PUNE — Approved 07-01-02 Revised 07-01.05 STATE OF INDIANA) INTHE —_COURT___ ) SS: c — DIVISION, Room) COUNTY OF __ ) CASENO,__ =) Petitioner ) vs. ) — —) — Respondent ) On for Protection and Request fora lieing’ / he Petitioner, fted a Petition for an Order equest fora Hearing, Check appropriate paragraph: Fee tls time, Lam requesting this Verified Request for Dismissal pursuant to 1C 34. st that the Coy 26-5-12. [respectfully reques urt grant this Request without delay or any Conditions, and dismiss the case without Prejudice. Begg Atihis time, Lam filing this Veri fied Request for Dismissal for an Order of Protection to terminate an Order of Pr —___ otection issued on Taffirm, under the penalties for Perjury, that the foregoing Tepresentations are true, DATE: ___ Petitioner’s Signature Printed Petitioner's Address Respondent’s Address