STATE OF SOUTH DAKOTA COUNTY OF ______________ DOMESTIC ) ) ) STALKING PERMANENT IN CIRCUIT COURT _________ JUDICIAL CIRCUIT EX PARTE TEMPORARY ORDER FOR PROTECTION TPO NO. _____________________ PETITIONER IDENTIFIERS: 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 First Middle Last SEX EYES RESPONDENT IDENTIFIERS: RACE H HEIGHT WEIGHT HAIR DATE OF BIRTH STATE EXPDATE Relationship to Petitioner: _____________________________________________ _____________________________________________ Respondent's Address: __________________________________________________ __________________________________________________ __________________________________________________ DRIVERS LICENSE # CAUTION: Weapon Involved 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 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-121F (Stalking Permanent Order) Rev. 07/01/16 American LegalNet, Inc. www.FormsWorkFlow.com ADDITIONAL FINDINGS: This matter came before this Court on this day and the following parties appeared personally: Petitioner Petitioner's Attorney ______________________ Other ______________ Respondent Respondent's 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: 1. That jurisdiction and venue are properly before this Court; and 2. By a preponderance of the evidence that: a) "stalking" as defined by SDCL 22-19A-1 has taken place; b) that the Petitioner has suffered physical injury resulting from an assault or a crime of violence, as defined by SDCL 22-1-2(9). THEREFORE, THIS COURT ORDERS THAT: 1. The Respondent is restrained from: a) following or harassing the Petitioner, or making any credible threat with the intent to place the Petitioner in reasonable fear of death or great bodily injury, SDCL 22-19A-1; b) harassing the Petitioner by means of any verbal, electronic, digital media, mechanical, telegraphic, or written communication, SDCL 22-19A-1; c) causing any injury as a result of an assault or crime of violence, SDCL 22-1-2-(9). 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) , (state)_______ (zip) (street/apt) (city) , (state)_______ (zip) (street/apt) (city) , (state)_______ (zip) This distance restriction applies unless otherwise specified in this order. 2 Form UJS-121F (Stalking Permanent Order) Rev. 07/01/16 American LegalNet, Inc. www.FormsWorkFlow.com 3) Phone calls, emails, third party contact, including 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 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. DATED / / . S