COURT'S REPORT ON APPLICATION/EXTENSION FOR ELECTRONIC COMMUNICATION INTERCEPT

Date: _______________________________
Court:  _____________________________				
Court ID#: __________________________ 
Regular Judge: ______________________
Judge in this matter: _________________				                               Office of Court Services
										
This report is being submitted pursuant to I.C. 35-33.5-2-5. It must be completed by any court to which an application for warrant authorizing interception of telephonic or telegraphic communication has been made under I.C. 35-33.5 et seq.  It must be submitted to the Executive Director of the Office of Court Services within 28 days after the termination of a warrant for interception or an extension, or within 28 days after the denial of an application for a warrant or an extension.

1.	Identity of person applying for warrant or extension:

Name: ___________________________________________ Title: _____________________________________
Address: ____________________________________________________________________________________
____________________________________________________________________________________________
2.  Type of warrant or extension applied for: ________________________________________________________
______________________________________ Case Number: __________________________________________
3.  Judicial action:			  Granted	 Modified	  Denied		     Date
     application for warrant         		_________	_________	_________	____________
     application for extension       		_________	_________	_________	____________
4.  Duration of interception:  _________________days 
5.  Number of extensions: _________      		 Duration of extensions: _______________days
6.  Offense for which the warrant or extension was issued or applied for:
_____________________________________________________________ (list most serious offense)
7. The nature and location of the place, facility, or device from which communications were to be intercepted:  ____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
8.  If notice was withheld pursuant to I.C. 35-33.5-4-3 from persons whose communications were intercepted, give the reasons for such withholding of notice:  __________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

                                                                                        ________________________________________
                                                                                                             Judge's signature
                                                                                         Prepared by: ___________________________
                                                                                         Telephone No.: _________________________
Mail to:  Office of Court Services
251 North Illinois Street, Suite 800
           	Indianapolis, Indiana   46204
          	Phone: (317) 232-2542 							EXEC-3533.5-1 Revised by Office of Court
Fax: (317) 233-6586						                    Services 12/23/2019 formerly EXEC-CR25(E)-1