County Court District Court Denver Juvenile Denver Probate _________________________________________ County, Colorado Court Address: Plaintiff/Petitioner: _________________________________ v. Defendant/Respondent: ________________________________ Policy Agency Case #: ________________________________ COURT USE ONLY Case Number: Division Courtroom VERBAL EMERGENCY PROTECTION ORDER ISSUED PURSUANT TO §13-14-103, C.R.S. To: _____________________________________________, Restrained Party. Sex: M F Race: _________ Date of Birth: _______________ Ht: ______ Wt: ______ Hair color: ______ Eye color: ______ The minor children are (list full name and date of birth): Full Name of Child Date of Birth Full Name of Child Date of Birth The grounds for requesting this Verbal Protection Order are as follows: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ The Court made the following findings based on the verbal statement presented above on _____________________ (date) and __________ (time): The issuance of a Verbal Protection Order was justified due to an imminent danger in close proximity that existed to the life or health of one or more persons or that danger existed to the life or health of the minor child in the reasonably foreseeable future. This Emergency Protection Order was granted verbally by telephone by ________________________(name of Judicial Officer) on the above date and time Therefore, it is Ordered that the Restrained Party: 1. Shall not contact, intimidate, threaten, molest, or injure ______________________________ (name of party) and/or the above-named children. 2. Shall be excluded from the family home or from the home of another party and shall stay at least ______ yards away from the following places: (Identify the address(es) where the Protected Party and children reside, work, or attend school.) Home: __________________________________________________________________________________ Work: Name: _______________________Address: ______________________________________________ School: Name: _______________________Address: ______________________________________________ Other: ___________________________________________________________________________________ Exceptions: ______________________________________________________________________________ 3. _________________________ (name of party) be awarded temporary care and control of the above-named children. 4. Additional Orders are as follows: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 5. This Emergency Protection Order expires on __________________ (date) no later than the close of judicial business on the next day of judicial business and must be filed with the county or district court as soon as possible. ________________________________________________ Signature of Peace Officer requesting verbal order By signing, I acknowledge receipt of this Order. ________________________________________________ Job Title Name of Agency ______________________________________ Signature of Restrained Party Date JDF 393 R1/05 VERBAL EMERGENCY PROTECTION ORDER PURSUANT TO §13-14-103, C.R.S. Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com IMPORTANT INFORMATION ABOUT PROTECTION ORDERS GENERAL INFORMATION This Order or injunction shall be accorded full faith and credit and be enforced in every civil or criminal court of the United States, Indian Tribe or United States Territory pursuant to 18 U.S.C. §2265. The Restrained Party may be subject to 18 U.S.C. §922(g)(8), which makes it unlawful for any person to possess or transfer a firearm who is subject to a court order that restrains such person from harassing, stalking or threatening an intimate partner of such person or the children of such intimate partner or person, or engaging in other conduct that would place an intimate partner in reasonable fear of bodily injury to the partner or children. NOTICE TO RESTRAINED PARTY A knowing violation of a protection order is a crime under §18-6-803.5, C.R.S. A violation may be subject you to fines up to $5000.00 and up to 18 months in jail. A violation may also constitute contempt of Court. You may be arrested without notice if a law enforcement officer has probable cause to believe that you have knowingly violated this Order. If you violate this Order thinking that the other party or the children named in this Order has given you permission, you are wrong, and can be arrested and prosecuted. The terms of this Order cannot be changed by agreement of the other party or the children. Only the Court can modify/dismiss this Order. NOTICE TO LAW ENFORCEMENT OFFICERS You shall use every reasonable means to enforce this Emergency Protection Order. You shall arrest, or, if an arrest would be impractical under the circumstances, seek a warrant for the arrest of the Restrained Person when you have information amounting to probable cause that the Restrained Person has violated or attempted to violate any provision of this Order and that the Restrained Person has been properly served with a copy of this Order or has received actual notice of the existence of this Order. You shall enforce this order even if there is no record of it in the Protection Order Central Registry. You shall take the Restrained Person to the nearest jail or detention facility. You are authorized to use every reasonable effort to protect the Protected Party and the named children to prevent further violence. You may transport or arrange transportation to a shelter for the Protected Party and the named children. JDF 393 R1/05 VERBAL EMERGENCY PROTECTION ORDER PURSUANT TO §13-14-103, C.R.S. Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com