STATE OF SOUTH DAKOTA COUNTY OF DOMESTIC EX PARTE TEMPORARY MODIFICATION ) ) ) STALKING PERMANENT IN CIRCUIT COURT JUDICIAL CIRCUIT ORDER FOR PROTECTION TPO NO. PETITIONER First Middle Last PETITIONER IDENTIFIERS: 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 RESPONDENT IDENTIFIERS: SEX RACE HEIGHT WEIGHT EYES HAIR DATE OF BIRTH STATE EXPDATE Relationship to Petitioner: DRIVERS LICENSE # Respondent's Address: Distinguishing Features: Weapon Involved 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 FINDS: 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) Form UJS-121C (Stalking Temporary Order) Rev. 07/01/16 1 American LegalNet, Inc. www.FormsWorkFlow.com Having considered the Petition and Affidavit presented by the Petitioner, this Court FINDS: 1. That jurisdiction and venue are properly before this Court; 2. That the Petitioner has alleged that the Respondent has willfully, maliciously, and repeatedly followed or harassed the Petitioner, or has made a credible threat with the intent to place the Petitioner in reasonable fear of death or great bodily injury, SDCL 22-19A-1; or 3. That the Petitioner has alleged that the Respondent has willfully, maliciously, and repeatedly harassed the Petitioner by means of verbal, electronic, digital media, mechanical, telegraphic, or written communication, SDCL 22-19A-1; or 4. That the Petitioner alleges that he/she has suffered physical injury as a result of an assault or a crime of violence, SDCL 22-1-2(9); and 5. That the Petitioner alleges that he/she will suffer immediate and irreparable injury, loss, or damage before the Respondent or the Respondent's attorney has an opportunity to be heard. THEREFORE THIS COURT ORDERS THAT THE RESPONDENT IS RESTRAINED FROM: a. FOLLOWING OR HARASSING PETITIONER, OR MAKING ANY CREDIBLE THREAT WITH THE INTENT TO PLACE PETITIONER IN REASONABLE FEAR OF DEATH OR GREAT BODILY INJURY, SDCL 22-19A-1; b. HARRASSING 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) D. The Petitioner's place of employment (street) (city) , (state) E. Other places , (state) (street/apt) (city) (street/apt) (city) , (state) , (state) (zip) (zip) (street/apt) (city) - (zip) (zip) (zip) This distance restriction applies unless otherwise specified in this order. 2 Form UJS-121C (Stalking Temporary Order) Rev. 07/01/16 American LegalNet, Inc. www.FormsWorkFlow.com 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 Order, deliver two copies of this Order and two copies of the Petition and Affidavit to the sheriff of this county. One copy of each shall be personally served by the sheriff upon the Respondent. 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 Temporary Order of Protection. Petitioner Respondent 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-121C (Stalking Temporary Order) Rev. 07/01/16 American LegalNet, Inc. www.FormsWorkFlow.com