Ex Parte Order of Protection File No. Chancery Court Hamilton County Tennessee Amended Order PETITIONER/PLAINTIFF First Middle PETITIONER/PLAINTIFF IDENTIFIERS Last Date of Birth of Petitioner Minor Children Protected Under this Order: ______________________________________________________ __________________________________________________________________________________________ V. RESPONDENT RESPONDENT IDENTIFIERS SEX EYES HAIR SOCIAL SECURITY # DRIVER’S LICENSE # First Middle Last Relationship to Petitioner:_______________________ RACE DOB HT WT EXP YR STATE Address & Phone No. _________________________ ____________________________________________ Distinguishing Features (include drug addition if any) Employer ____________________________________ ________________________________________________ ____________________________________________ ________________________________________________ CAUTION: Weapon Involved Respondent owns/possesses a firearm Relationship Identifiers (Mark all that apply): Current or Former Spouses Parents of Child in Common Child of Respondent Child of Respondent’s Intimate Partner Live Together of Have Lived Together Other (Explain): ________________________________ TO THE RESPONDENT: It appears to the Court from the sworn petition for an order of protection that such an order should issue pursuant to Tennessee Code Annotated, title 36, chapter 3, part 6. IT IS, THEREFORE, ORDERED as follows. 1. You shall not commit or threaten to commit domestic abuse against Petitioner or Petitioner’s minor children. 2. You shall not telephone, contact, or otherwise communicate with Petitioner, directly or indirectly. 3. If you violate this order, you may be held in contempt of Court and punished by incarceration and/or a fine. 4. A hearing on this matter will be held on the date set out below and you have a right to secure counsel to represent you at the hearing. Page 1 of 2 pages. EX PARTE ORDER OF PROTECTION Form 028, Rev. 2006.01.13 American LegalNet, Inc. www.USCourtForms.com 5. Pursuant to Tennessee Code Annotated § 36-3-609, a copy of this order shall be issued to all local law enforcement agencies in Hamilton County. 6. Pursuant to Tennessee Code Annotated § 36-3-611, you shall be arrested by a law enforcement officer without a warrant if that officer has reasonable cause to believe you have violated or are violating this order. 7. This ex parte order shall remain in effect for 15 days after service or until changed by this court. _____________________________ __________________________________________ DATE CHANCELLOR TO RESPONDENT. If you violate this order thinking that Petitioner has given you permission to do so, you are wrong and can be arrested and prosecuted. The terms of this order can not be changed by agreement of the parties. Only the court can change this order. Willful violation of this order by Respondent will constitute contempt of court. Potential penalties include up to 10 (ten) days in jail and a $50.00 fine for each violation. The court may also impose a civil penalty of up to $50.00 for each violation pursuant to T.C.A. § 36-3-610. TO RESPONDENT. You are subject to prosecution for Aggravated Assault, a Class C felony, if after having been enjoined or restrained by this or any other order, diversion or probation agreement from any way causing or attempting to cause bodily injury or in any way committing or attempting to commit an assault against an individual or individuals, you intentionally or knowingly attempt to cause or do cause bodily injury or commit or attempt to commit an assault against such individual or individuals. T.C.A. § 39-13-102(c). DATE OF HEARING: _________________________________ AT _________a.m./p.m. (Eastern Time) PLACE OF HEARING: ___________________________________________________________ RETURN OF SERVICE Served on Respondent on ________________, 20_____ at ______ a.m./p.m. by ( one): by personal service on a resident of Tennessee, OR by mail on a non-resident of Tennessee in the manner as set forth in Tennessee Code Annotated §§ 20-2-215 and 20-2-216, _______________________________________ Clerk/Deputy Clerk or Authorized Officer Page 2 of 2 pages. EX PARTE ORDER OF PROTECTION Form 028, Rev. 2006.01.13 American LegalNet, Inc. www.USCourtForms.com