1 of 5 DR - - Ex Parte Order of Protection Amended Order Case No. Circuit Court, Div. County: Petitioner/Plaintiff , Arkansas This Order is Effective Until: First Middle Last Race Sex Minor Children Protected under this Order Verses Respondent/Defendant Respondent Identifiers First Middle Last CAUTION : Respondent possesses a firearm Respondent has history of extreme violence d.o.b. d.o.b. d.o.b. d.o.b. Sex Race DOB mm/dd/yyyy Ht. Wt. Address: Work: Eyes Hair SS# Phone # DL # or other ID # Pursuant to Federal law, this Order shall be enforced by law enforcement officers in all states, territories, districts and tribal lands regardless of whether this Order of Protection is registered locally. American LegalNet, Inc. www.FormsWorkFlow.com 2 of 5 DR - - Relationship Identifiers : Current or former spouses Parents of child(ren) in common Live together Current or past dating relationship Other Re lative (Explain) THE COURT HEREBY FINDS AND ORDERS: That there is jurisdiction over the parties and subject matter, and the Petitioner has presented sufficient evidence to show: 1.) that the victim(s) is (are) in immediate and present danger of domestic abuse or 2.) that the Respondent is scheduled to present danger of domestic abuse. That an Ex Parte Temporary Order of Protection is hereby granted pursuant to the terms herein. The Respondent is ordered to appear before the Court on the day of , 20, at .m. in the Courthouse located atAR. If you fail to appear, the Court will likely make this Order permanent without further notice to you. The Respondent is hereby restrained from committing any criminal act against the victim(s) including, but not limited to: acts of violence or Domestic Abuse, A.C.A. 2479-15-103(3); Harassment A.C.A. 2475-71-208; Harassing Communications A.C.A. 2475-71-209; Stalking A.C.A. 2475-71-229; orTerroristic Threatening A.C.A. 2475-13-301. The Respondent is prohibited from initiating any contact with the victim(s) includin g but not limited to physical presence, telephonic, electronic, oral, written, visual, or video. Respondent also shall not use a third party to contact the victim(s) except by legal counsel or as authorized by law or court order. The Respondent is (or) The Petitioner's address is excluded from notice to the Respondent. The Respondent is prohibited from the following places: Workplace: School: Other (Identify): is awarded temporary custody of minor child(ren): American LegalNet, Inc. www.FormsWorkFlow.com 3 of 5 DR - - ( Children's Names) Any law enforcement officer with jurisdiction is ordered to assist the Petitioner in gaining possession of the dwelling and/or to otherwise assist in execution of the Order of Protection. A law enforcement officer with jurisdiction is ordered to serve the Order of Protection on the Respondent . A law enforcement officer with jurisdiction is ordered to assist the Petitioner in obtaining his or her personal effects from the dwelling upon proper and timely request of the Petitioner. A law enforcement officer with jurisdiction is ordered to assist the Respondent in obtaining his or her personal effects from the dwelling upon proper and timely request of the Respondent . Other Orders : Respondent is temporarily prohibited from terminating the account(s) associated with the following telephone number(s): If the parties (or other persons named herein) are subject to the jurisdiction of another court (i.e. through a divorce or paternity action), upon proper notice and the opportunity to be heard, said court may amend the terms of this Order as appropriate. On this day of , 2, IT IS ORDERED. CIRCUIT JUDGE/DISTRICT JUDGE Office of the Circuit Clerk, County, Arkansas American LegalNet, Inc. www.FormsWorkFlow.com 4 of 5 DR - - WARNINGS TO RESPONDENT - Pursuant to A.C.A. 2479 - 15 - 207, a violation of an Order of Protection is a Class A misdemeanor carrying a maximum penalty of one year imprisonment in the county jail or a fine of up to $2,500, or both. A violation of an Order of Protection under this sectio n within five (5) years of a previous conviction for violation of an Order of Protection is a Class D felony punishable by up to six years in prison or up to a $10,000 fine or both. - It is a federal offense for an individual who is subject to a Final Orde r of Protection or convicted of a misdemeanor of domestic violence to ship, transport, or possess a firearm or ammunition pursuant to U.S.C. 247922(g)8) and (9). - Crossing state, territorial, or tribal boundaries to violate this Order may result in federal imprisonment pursuant to 18 U.S.C. 2472262. NOTICE TO LAW ENFORCEMENT - This Order of Protection is enforceable in every county of this state by any court or law enforcement officer. See A.C.A. 2479 - 15 - 207(g). PROOF OF SERVICE Case #: Court Date: SERVED: Date Time Place Attempts Made: List only date and time 1) 2) 3 ) Served On (Print Name) Manner of Service Served By (Print Name) Title Badge # American LegalNet, Inc. www.FormsWorkFlow.com 5 of 5 DR - - DECLARATION OF SERVER I declare, under penalty of perjury under the laws of the State of Arkansas , that the foregoing information contained in the proof of service is true and correct. Executed on Date Signature of Server Address of Server American LegalNet, Inc. www.FormsWorkFlow.com