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STATE OF INDIANA ) IN THE CIRCUIT/SUPERIOR COURT No. ) SS: COUNTY OF HAMILTON ) CAUSE NO. 29 STATE OF INDIANA v. (Defendant’s name) REQUEST FOR OUT OF STATE TRAVEL PERMIT Name: Date of birth: Home address: Destination: Purpose of trip: I plan to leave on , 20 and to return on , 20 . I will travel by (automobile, airliner, train, etc.): My companion(s) will be (name and relationship): . WAIVER OF EXTRADITION I hereby agree to waive extradition to the state of Indiana and agree that I will not contest any effort by any state to return me to the state of Indiana. Failure to comply with the above will be deemed to be a violation of the terms and conditions of the Court for which I may be returned to the State of Indiana. Date: Defendant’s signature: _ IF ON PRETRIAL SUPERVISION, THE DEFENDANT MUST OBTAIN THE FOLLOWING: Pretrial’s Recommendation: (check one) ⎕Approve ⎕Disapprove Reason: Pretrial Personnel Signature COURT’S ORDER ON DEFENDANT’S REQUEST FOR TRAVEL PERMIT The Court hereby grants the Defendant permission to travel as requested. ⎕ Special conditions (if checked): Date: Judge, Hamilton Circuit/Superior Court