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Ired ) DETAILS OF PERSON TO BE RESTRAINED SURNAME FIRST NAME MIDDLE NAME ALIAS COURT FILE NO. ADDRESS D.O.B. / yyyy / SEX HT WT HAIR EYES / mm / dd Scars, marks, or distinguising features Prepared by (Name, please print) Date Prepared yyyy mm dd Signature Name of Judge Date of Order / yyyy / mm Court Location Court Division OTTAWA FAMILY DIVISION Date of Revocation / / yyyy/ mm / dd Date of Modification / / yyyy/ mm / dd Area of Modification / / Date of Order yyy.

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