Temporary Order of Protection (Ex Parte Order of Case # (the clerk fills this in): Protection) Petitioner is under 18 Court of In the County, TN Petitioner (person needing protection) If Petitioner is under 18, insert child’s name if filed on behalf of an unemancipated person (someone under 18 years of age) pursuant to TCA §36-3602. This request is being made by ____________________________ who is child’s parent or legal guardian or a caseworker. _____________________________________________________________________________________________________________________ first middle last Petitioner’s children under 18 protected by this Order: Name Age Relationship to Respondent Name 1. Relationship to Respondent 3. 2. Age 4. Respondent’s Information (person you want to be protected from): first middle _ date of birth (MM/DD/YYYY) last street address city state zip Respondent’s Employer: Employer’s name Employer’s phone # Describe Respondent: Sex Race Hair Eyes Male White Black Brown Female Asian Grey Hazel Height – Weight – SSN – Other Height Weight Social Sec. # (Provided to Clerk’s Office if Black Blond Blue Hispanic Bald Green Other: Brown Grey Scars/Special Features Other:______ Other: Phone Number known) Petitioner’s relationship to the Respondent (Check all that apply): We are married or used to be married. We live together or used to live together. We have a child together. We are dating, used to date, or have had sex. We are relatives, related by adoption, or are/were in-laws. (Specify): We are the children of a person whose relationship is described above (Specify): The Respondent has stalked me. The Respondent has sexually assaulted me. Other: The Court having reviewed the Petition for Temporary Order of Protection and finding, pursuant to TCA §36-3-605(a), that Petitioner is under an immediate and present danger of abuse from the Respondent and good cause appearing, the court issues the following: Warning! Weapon involved Has or owns a weapon Orders to the Respondent: Do not abuse, threaten to abuse, hurt or try to hurt, or frighten Petitioner and/or Petitioner’s minor children under 18. Do not put Petitioner and/or Petitioner’s minor children under 18 in fear of being hurt or in fear of not being able to leave or get away. Do not stalk or threaten to stalk Petitioner and/or Petitioner’s minor children under 18. Do not come about the Petitioner and/or Petitioner’s minor children protected by this order (including coming by or to a shared residence) for any purpose. This is a Court Order Temporary Order of Protection (ORDER OF THE COURT) page 1 of 2 06/10/11 American LegalNet, Inc. www.FormsWorkFlow.com Do not contact the Petitioner and/or Petitioner’s minor children protected by this order either directly or indirectly, by phone, email, messages, mail or any other type of communication or contact. If the parties share(d) a residence, Respondent must immediately and temporarily vacate the residence shared with the Petitioner, pending a hearing on the matter. If the parties shared a residence, Respondent can obtain his/her clothing and personal effects such as medicine as follows: (List process as approved by local law enforcement personnel) _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ You must not hurt or threaten to hurt any animals owned or kept by the Petitioner/Petitioner’s children. Other orders: __________________________________________________________________________ Go to court on (date): at a.m. p.m. at (location): You must obey these orders until the date of the hearing or until changes are made by the court. If you do not agree with these orders, go to the court hearing and tell the court why. If you do not go, the court can make orders against you. You have the right to bring your own lawyer. If you do not obey all orders on this form, you may be fined and sent to jail. Only the court can change this Order. Neither you nor the Petitioner can agree to change this Order. Even if the Petitioner tries to contact you or agrees to have contact with you, you must obey this Order. If you do not, you can be sent to jail for up to 10 days and fined up to $50 for each violation (TCA § 36-3-610) Date: Time: a.m. p.m. Judicial officer’s signature Warnings to Respondent: The court will send a copy of this Order to all law enforcement agencies in this county. Any law enforcement officer who reasonably believes you have disobeyed this Order may arrest you. If you hurt or try to hurt anyone while this Order, probation or diversion is in effect, you may face separate charges for aggravated assault, a Class C felony. (TCA § 39-13-102(c)) Proof of Service The Respondent was served copies of the Petition, Notice of Hearing, and Temporary Order of Protection on: a.m. (date): at (time): p.m. by (check one): Personal service U.S. Mail per TCA §§ 20-2-215 and 20-2-216 (The Respondent does not live in Tennessee.) If the Petitioner is under 18 and serving these documents would not put him/her at risk, the Clerk will serve and fill out below. (TCA § 36-3-605(c)) I served the child’s parents copies of the Petition, Notice of Hearing, and Temporary Order of Protection by personal delivery or U.S. Mail on: (date): at (address): Clerk’s signature: Server’s signature This is a Court Order Temporary Order of Protection (ORDER OF THE COURT) 06/10/11 page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com