IN THE COURT OF COMMON PLEAS

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IN THE COURT OF COMMON PLEAS DOMESTIC RELATIONS DIVISION WAYNE COUNTY, OHIO Petitioner’s Name CASE NO. Address City, State, Zip JUDGE -VS- MAGISTRATE Respondent’s Name Address MOTION TO MODIFY, EXTEND, City, State, Zip OR TERMINATE CIVIL PROTECTION ORDER Now comes _________________________________, Petitioner/ Respondent (check one), and requests this Court to: ☐ Modify Civil Protection Order ☐ Extend Civil Protection Order ☐ Terminate Civil Protection Order dated __________________(month) ___________(day), _____________ (year). The reasons for this request are: ______________________________________ Signature of Petitioner/ Respondent (check one) Sworn to and subscribed before me on this ____ day of _________________, _________. ______________________________________ Notary Public

NOTICE OF HEARING A hearing on this Motion shall be held before the above-named Magistrate on the _______ day of ___________________(month), _____________(year), at ________ a.m./p.m. in Courtroom _______at the Wayne County Domestic Relations Court, 107 W. Liberty St. Wooster, OH 44691. REQUEST FOR SERVICE Please serve a copy of the foregoing Motion upon___________________________(name) by certified mail, return receipt requested, at the following address: ________________________________________________________________________ ________________________________________________________________________. ______________________________________ Signature of Petitioner/ Respondent (check one)