Ex Parte Order of Protection Case No. Court _____________________________ County Tennessee Amended Order PETITIONER/PLAINTIFF First Middle Last PETITIONER/PLAINTIFF IDENTIFIERS Date of Birth of Petitioner Minor Children Protected Under this Order: ________________________________________________ ________________________________________________ V. RESPONDENT RESPONDENT IDENTIFIERS SEX First Middle RACE DOB HT WT HAIR SOCIAL SECURITY # Last EYES Relationship to Petitioner _________________________________ Address & Phone No. ____________________________________ ________________________________________________________ Respondent’s Employer __________________________________ Distinguishing Features ____________________________ _______________________ CAUTION: Weapon Involved Respondent owns/possesses a firearm Relationship Identifiers (Mark all that apply): Parents of Child in Common Child of Respondent Live Together or Have Lived Together Current or Former Spouses Child of Respondent's Intimate Partner 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, ADJUDGED, AND DECREED: 1. That you shall not commit or threaten to commit abuse, domestic abuse, stalking or sexual assault against the petitioner or petitioner’s minor children. Abuse means: a. Inflicting or attempting to inflict physical injury by other than accidental means b. Placing one in fear of physical harm or physical restraint c. Malicious damage to personal property including inflicting or attempting to inflict or placing one in fear of infliction of physical harm or injury on any animal owned, possessed, leased, kept or held by petitioner or petitioner’s minor children. Revised 7-1-07 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com 2. That you shall not telephone, contact, or otherwise communicate with the petitioner, directly or indirectly; 3. That if you violate this order, you may be held in contempt of Court and punished by incarceration and/or a fine; 4. That 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; 5. That, pursuant to Tennessee Code Annotated § 36-3-609, a copy of this order be issued to all local law enforcement agencies in ___________________________ County; 6. That, 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 that you have violated or are violating this order. 7. That this ex parte order shall remain in effect for 15 days after service or until changed by the court. 8. _____That a copy of the Petition, Notice of Hearing and Ex-Parte Order shall be served upon the parents of the Petitioner (If Petitioner is a minor) pursuant to T.C.A. 36-3-605 (c ). ______________________________ DATE _____________________________________ JUDGE/MAGISTRATE TO THE RESPONDENT: If you violate this order thinking that the 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 the respondent will constitute contempt of court and 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 THE 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. PLACE OF HEARING Return of Service Served on Respondent by [check 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, on _____________________, 20_____ at ______ a.m./p.m. ____________________________________________ [Signature of person serving Order on Respondent] Certificate of Service (Applicable only if the Petitioner is a minor unless the court finds that such service would create a threat of serious harm to the minor child Petitioner. (T.C.A. 36-3-605(c)). I certify that the foregoing has been delivered in person or sent by U.S. Mail to the parents of the minor Petitioner at the following address: _______________________________________. I did so on the _____ day of ______________________, 200__. __________________________________ Clerk Revised 7-1-07 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com Ex Parte Order of Protection - Warnings to Respondent - Notice of Hearing ADVERTENCIAS AL QUERELLADO ORDEN DE PROTECCIÓN UNILATERAL Al querellado: Si viola esta orden porque cree que la parte solicitante le ha dado permiso para hacerlo, está usted equivocado y puede ser detenido y procesado. Un acuerdo entre las partes no surte efecto para camibar los términos de esta orden ya que solamente el tribunal tiene la autoridad para hacerlo. Si el querellado infringe intencionalmente esta orden será culpable de desacato a los tribunales, y se expone a las siguientes penas posibles de hasta 10 (diez) días en la cárcel y de una multa de $50.00 por cada incidente. El tribunal puede imponer también una pena civil de hasta $50.00, por cada incidente, conforme al Código Anotado de Leyes de Tennessee, en su artículo 36-3-610. Al querellado: Usted se expone a ser procesado por agresión con agravantes, un delito mayor, Clase C, si conforme a esta orden o a cualquier otra orden, acuerdo para un programa de readaptación social, o para libertad condicional lo prohíben o restringen de lesionar o intentar lesionar, o de cualquier manera cometer o intentar cometer una agresión contra una determinada persona o determinadas personas, y en lo sucesivo comete o intenta cometer una agresión, intencionalmente o con pleno conocimiento, contra esas mismas personas. Disposición recogida en el Código Anotado de Leyes de Tennessee , en su artículo 39-13-102. FECHA DE LA AUDIENCIA_______________________A LAS_________a.m./p.m. LUGAR DE LA AUDIENCIA_____________________________________________ Revised 7-1-07 American LegalNet, Inc. www.FormsWorkflow.com