STATE OF SOUTH DAKOTA COUNTY OF ______________ DOMESTIC ) ) ) STALKING PERMANENT IN CIRCUIT COURT _________ JUDICIAL CIRCUIT ORDER FOR PROTECTION TPO NO. _____________________ PETITIONER IDENTIFIERS: EX PARTE TEMPORARY MODIFICATION PETITIONER First Middle Last Date of Birth of Petitioner By (name and DOB): ___________________________ _____________________________________________ On behalf of a minor child by parent/guardian. Other Protected Persons (name and DOB):___________ ______________________________________________ __________________________________________ (See also 2B Additional Orders.) V. RESPONDENT SEX First Middle Last RESPONDENT IDENTIFIERS: RACE H HEIGHT WEIGHT HAIR DATE OF BIRTH STATE EXPDATE EYES Relationship to Petitioner: _____________________________________________ _____________________________________________ Respondent's Address: __________________________________________________ __________________________________________________ __________________________________________________ DRIVERS LICENSE # Distinguishing Features: _____________________________________________ _____________________________________________ CAUTION: Weapon Involved 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 Respondent's due process rights. THE COURT ORDERS: That the Respondent is restrained from acts of abuse and physical harm, making threats of abuse, 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: Month/Day Year through Month/Day Year 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.§2265). Crossing state, territorial, or tribal boundaries to violate this order may result in federal imprisonment (18 U.S.C. §2262). 1 Form UJS-121E (Stalking Modification of Temporary Order) Rev. 07/01/2016 American LegalNet, Inc. www.FormsWorkFlow.com Therefore, having considered the Motion to Modify presented to the Court, this Court FINDS: The original ex parte temporary order of protection will be modified as follows: ADDITIONAL ORDERS: 1) That the Respondent is excluded from the Petitioner's residence listed in 2C. 2) That the Respondent shall not come within a distance of ___________ from the following persons and places: A. The Petitioner personally B. The following minor children named as other protected persons: Name ___________________________ ___________________________ ___________________________ Date of birth ___________ ___________ ___________ Relationship _______________________________ _______________________________ _______________________________ C. The Petitioner's residence(street/apt)_______________________________________________ (city)_______________________________, (state) _______ (zip) _________-_______ D. The Petitioner's place of employment (street)________________________________________ (city)_______________________________, (state) _______ (zip) __________- _______ E. Other places (street/apt) (city) (street/apt) (city) (street/apt) (city) , (state)_______ (zip) This distance restriction applies unless otherwise specified in this order. 3) Phone calls, emails, third party contact, and correspondence, direct or indirect, are not permitted, to a protected person, except as follows: ___________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 4) Respondent is ordered to immediately turn over all weapons and ammunition to local sheriff. 5) 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 order's 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 modified Order, deliver two copies of this order and two copies of the Motion to Modify to the sheriff of this county. One copy of each shall be personally served by the sheriff upon the Respondent. 2 Form UJS-121E (Stalking Modification of Temporary Order) Rev. 07/01/2016 American LegalNet, Inc. www.FormsWorkFlow.com , (state)_______ (zip) , (state)_______ (zip) - DATED / / . Service of this order is authorized on any day including Sunday. Judge Attest: By: , Clerk of Courts , Deputy NOTICE OF ENTRY OF ORDER AND ACKNOWLEDGMENT OF PERSONAL SERVICE I acknowledge receipt of a copy of this Modification of Temporary 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. 3 Form UJS-121E (Stalking Modification of Temporary Order) Rev. 07/01/2016 America