STATE OF SOUTH DAKOTA COUNTY OF ______________ ) ) ) IN ___________ COURT _________ JUDICIAL CIRCUIT VULNERABLE ADULT ABUSE EX PARTE TEMPORARY PERMANENT ORDER FOR PROTECTION TPO NO. _____________________ MODIFICATION PETITIONER First Middle Last PETITIONER IDENTIFIERS: Date of Birth of Petitioner By Substitute Petitioner (name and DOB): _____________________________________________ On behalf of the Vulnerable Adult Petitioner. V. RESPONDENT First Middle Last Substitute Petitioner's Relationship to Petitioner: ___________________________________________ ___________________________________________ RESPONDENT IDENTIFIERS: RACE H HEIGHT WEIGHT HAIR DATE OF BIRTH STATE EXPDATE SEX EYES Relationship to Petitioner: _____________________________________________ _____________________________________________ Respondent's Address: _____________________________________________ _____________________________________________ _____________________________________________ CAUTION: Weapon Involved DRIVERS LICENSE # Distinguishing Features: _____________________________________________ _____________________________________________ THE COURT FINDS: That it has jurisdiction over the parties and subject matter, and 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 physical abuse, emotional and psychological abuse, neglect, and financial exploitation of a vulnerable adult. 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 Or if a permanent order is issued, until that order is served. Year through Month/Day Year Only this Court can change this Order. 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). Page 1 of 3 UJS-120C (Vulnerable Adult) Temporary Order Rev. 6/16 American LegalNet, Inc. www.FormsWorkFlow.com Having considered the Petition and Affidavit presented by the Petitioner or Substitute Petitioner, this Court FINDS: A. That jurisdiction and venue are properly before this Court; B. That the above-named Petitioner is eligible for a vulnerable adult protection order pursuant to SDCL ch. 21-65; C. That the Petitioner or Substitute Petitioner has alleged that the Respondent has committed one or more acts of vulnerable adult abuse as defined by law; and D. That the Petitioner or Substitute Petitioner alleges that the Petitioner is in present danger of vulnerable adult abuse before the Respondent or the Respondent's attorney can be heard in opposition. ADDITIONAL ORDERS: 1) The Respondent is excluded from the Petitioner's residence listed in 2B. 2) The Respondent shall not come within a distance of ___________ from the following persons and places: A. The Petitioner personally B. The Petitioner's residence (street/apt)_______________________________________________ (city)_______________________________, (state) _______ (zip) _________-_______ C. The Petitioner's place of employment (street)________________________________________ (city)_______________________________, (state) _______ (zip) __________- _______ D. 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 Respondent is restrained from exercising any powers on behalf of the Petitioner through a courtappointed guardian, conservator, or guardian ad litem, an attorney in fact, or another third party. 4) This Court FINDS that Respondent has financially exploited the Petitioner pursuant to SDCL 21-65-1(7) and 21-65-12 and ORDERS: A. The Respondent is restrained from exercising control over the funds, benefits, property, resources, belongings, or assets of the Petitioner, except as otherwise provided for in this Order. B. The Respondent shall return custody or control of the funds, benefits, property, resources, belongings, or assets: To the Petitioner. To the Petitioner's guardian / conservator / attorney in fact, namely ____________________. (circle) C. The Respondent shall follow the instructions of the guardian, conservator, or attorney in fact of the Petitioner, namely _____________________________. D. The Respondent is prohibited from transferring any funds, benefits, property, resources, belongings, or assets of the Petitioner to any person other than the Petitioner, except as otherwise provided in this Order. 5) Phone calls, emails, third party contact, including correspondence, direct or indirect, are not permitted, to Petitioner, except as follows: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com UJS-120C (Vulnerable Adult) Temporary Order Rev. 6/16 6) Other relief as follows:______________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ WARNING TO RESPONDENT: You may be held in contempt 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. 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. DATED / / . Service of this Order is authorized on any day including Sunday. Judge Attest: By: , Clerk of Courts , Deputy Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com UJS-120C (Vulnerable Ad