Form UJS-091I (Domestic Modification of Permanent Order) Rev. 01/1 1 STATE OF SOUTH DAKOTA ) IN CIRCUIT COURT ) COUNTY OF ) JUDICIAL CIRCUIT DOMESTIC STALKING EX PARTE TEMPORARY PERMANENT MODIFICATION ORDER FOR PROTECTION TPO NO. PETITIONER First Middle Last By (name and DOB): On behalf of a minor child by parent/guardian. V. RESPONDENT First Middle Last Relationship to Petitioner: Respondent222s Address: CAUTION: Weapon Involved PETITIONER IDENTIFIERS: Date of Birth of Petitioner Other Protected Persons (name and DOB): (See also 2B Additional Orders.) RESPONDENT IDENTIFIERS: SEX RACE H H EIGHT WEIGHT EYES HAIR DATE OF BIRTH DRIVERS LICENSE # STATE EXPDATE Distinguishing Features: THE COURT FINDS: That it has jurisdiction over the parties and subject matter, and the Respondent has been provided with reasonable notice and opportunity to be heard, and that in the case of an ex parte order, the Respondent will be provided with reasonable notice and opportunity to be heard sufficient to protect the Respondent222s due process rights. THE COURT ORDERS: That the Respondent is restrained from acts of abuse and physical harm, attempted or threatened abuse and physical harm, stalking or harassment. That the Respondent is restrained from contact with the Petitioner by any direct or indirect means except as authorized in this order. Additional findings and orders are on the following pages. This order shall be effective through Month/Day Year Month/Day Year Or if a permanent protection order is issued, until that order is served. Only this Court can change this order. VIOLATION OF THIS PROTECTION ORDER IS A CRIMINAL OFFENSE. WARNING TO RESPONDENT: This order shall be enforced, even without registration, by courts of any state, the District of Columbia, any U.S. Territory, and may be enforced by Tribal Lands (18 U.S.C.2472265). Crossing state, territorial, or tribal boundaries to violate this order may result in federal imprisonment (18 U.S.C. 2472262). American LegalNet, Inc. www.FormsWorkFlow.com Form UJS-091I (Domestic Modification of Permanent Order) Rev. 01/1 2 ADDITIONAL FINDINGS: This matter came before this Court on this day and the following parties appeared personally: Petitioner Petitioner222s Attorney Other Respondent Respondent222s Attorney Other 1)This Court FINDS that, without admitting to the allegations in the Petition, the Respondent waives further hearing, findings of fact, and conclusions of law, and stipulates to the entry of an Order of Protection on the terms specified below. 2)Having considered the evidence presented and any affidavits and pleadings on file, this Court FINDS: A. That jurisdiction and venue are properly before this Court; B. That the above-named Petitioner is eligible for a protection order pursuant to SDCL Ch. 25-10; C. By a preponderance of the evidence that "domestic abuse" as defined by SDCL 25-10-1(1) has occurred; and D. That the Respondent had actual notice of the hearing and an opportunity to participate. E. That the Motion to Modify is granted and modified terms incorporated herein. ADDITIONAL ORDERS: 1)The Respondent is excluded from the Petitioner222s residence listed in 2C. 2)That the Respondent shall not come within a distance of from the following persons andplaces: A. The Petitioner personally B. The following minor children named as other protected persons: Name Date of birth Relationship C. The Petitioner222s residence(street/apt) (city), (state) (zip) - D. The Petitioner222s place of employment (street) (city), (state) (zip) - E. Other places (street/apt) (city) , (state) (zip) - (street/apt) (city) , (state) (zip) - (street/apt) (city) , (state) (zip) - This distance restriction applies unless otherwise specified in this order. 3)The Petitioner shall have temporary custody of the minor child(ren), whose names are: 4)Temporary visitation for the respondent with the minor child(ren) named above shall consist of: Existing order in File # Supervised at Jurisdiction: South Dakota South Dakota tribe Other State Other Other Visitation: American LegalNet, Inc. www.FormsWorkFlow.com Form UJS-091I (Domestic Modification of Permanent Order) Rev. 01/1 3 5)The Respondent shall pay temporary: child support in the amount of $ a month starting on and continuing until further order of the Court; Child support shall be paid to: Kneip Building 700 Governors Drive Pierre, SD 57501 spousal support in the amount of $ a month starting on and continuing until further order of the Court. Spousal support shall be paid to the Clerk of Courts Office in the county this order was filed. 6)Phone calls, emails, third party contact, including correspondence, direct or indirect, are not permitted, to a protected person, except as follows: 7)The Respondent shall receive parenting classes approved or provided by the Department of Social Services, pursuant to SDCL 25-10-5, and that a Certificate of Completion of the parenting classes befiled by Respondent no later than (date): 8)Respondent is ordered to immediately turn over all weapons and ammunition to local sheriff. 9)Other relief as follows: WARNING TO RESPONDENT: You can be arrested for violating this protection order even if any person protected by the order initiates the contact or invites you to violate the order222s prohibitions. Only the court can change the order; the protected person cannot waive any of its provisions. You may also be held in contempt for ignoring the terms of this protection order. AND IT IS FURTHER ORDERED THAT: the Petitioner shall, immediately upon the granting of this Order, deliver two copies of this Order to the sheriff of this county. One copy shall be personally served by the sheriff upon the Respondent, unless personal service has been acknowledged below. American LegalNet, Inc. www.FormsWorkFlow.com Form UJS-091I (Domestic Modification of Permanent Order) Rev. 01/1 4 DATED / / . Service of this order is authorized on any day including Sunday. Judge Attest: , Clerk of Courts By: , Deputy NOTICE OF ENTRY OF ORDER AND ACKNOWLEDGMENT OF PERSONAL SERVICE I acknowledge receipt of a copy of this Order of Protection. Petitioner Date Respondent Date UNDER A PERMANENT PROTECTION ORDER: You may be subject to the following federal laws: (1) Effective immediately, you may not possess, carry, ship or transport any firearm or ammunition that has been transported in interstate or foreign commerce while this Protection Order is in effect. Title 18 United States Code Section 922(g)(8). (2) If you violate this Protection Order and are convicted of an offense of domestic violence, you may be forbidden for life from possessing, carrying, shipping or transporting, any firearm or ammunition that has been transported in interstate or foreign commerce. Title 18 United States Code Section 922(g)(9). Violation of these federal laws carries a maximum penalty of ten years in prison, a $250,000 fine, or both. American LegalNet, Inc. www.FormsWorkFlow.com