Case No. Court _____________________________ County Tennessee Order of Protection 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): ____________________________ THE COURT HEREBY FINDS: That it has jurisdiction over the parties and subject matter, and the Respondent has been provided with reasonable notice and opportunity to be heard. Additional findings of this order are as set forth below: THE COURT HEREBY ORDERS: That the above named Respondent be restrained from committing further acts of abuse, stalking or sexual assault or threats of abuse, stalking or sexual assault against petitioner or petitioner’s minor children. That the above named Respondent be restrained from any contact with the Petitioner/Plaintiff. Additional terms of this order are as set forth below. The terms of this order shall be effective until Revised 7-1-05 , , . Page 1 of 4 American LegalNet, Inc. www.USCourtForms.com THE COURT FURTHER FINDS AS FOLLOWS: (STRIKE OUT FINDINGS THAT DO NOT APPLY) That the Respondent has committed against the Petitioner the following: 1. Domestic Abuse in that Respondent committed the acts alleged in the Petition, the court hereby adopting the alleged acts as findings of fact and incorporating the same by reference; OR committed the following acts: __________________________________________________________________________________ ______________________________________________________________________________________. 2. Stalking 3. Sexual Assault That Respondent represents a credible threat to the physical safety of petitioner; that respondent received actual notice of the hearing; that respondent had an opportunity to participate in the hearing. ______ That Tennessee is the home state of the parties’ minor child(ren) and the Court has jurisdiction over child custody. OR ______ That the minor child(ren) is/are present in this State and that petitioner and/or the minor child(ren) has/have been subjected to or threatened with mistreatment or abuse and the Court has temporary emergency jurisdiction over child custody. [If there is a previous or pending child custody proceeding in another State having jurisdiction under the UCCJEA:] Such temporary emergency jurisdiction shall expire on _______________________, 20______ or when an Order is obtained from the Court of the other State. IT IS FURTHER ORDERED AS FOLLOWS: That the respondent shall not commit domestic abuse, stalking or sexual assault or threaten to commit domestic abuse, stalking or sexual assault against the petitioner or the petitioners’ minor child(ren); or use or threaten physical force that would reasonably be expected to cause bodily injury. (X where applicable:) _______ The respondent is hereby ordered to refrain from telephoning, contacting, or otherwise communicating with the petitioner, directly or indirectly, or coming about petitioner or petitioner's residence or place of employment for any purpose; _______ The petitioner is awarded custody of the parties’ minor child(ren). _______ Respondent shall have visitation with the parties’ minor child(ren) at the following times: ________________________________________________________________________________ ________________________________________________________________________________ ________ Visitation shall be supervised by _________________________________________________. ________ Exchange of the parties’ minor child(ren) for the purposes of visitation shall take place at the following location:________________________________________________________________________ ______ Respondent shall pay $___________ per __________ for the support of the parties’ minor child(ren) based on the Tennessee Child Support Worksheet* attached hereto. There is no deviation from the Tennessee Child Support Guidelines. There is deviation from the Tennessee Child Support Guidelines as follows: ____________________________________________________________________________ ___________________________________________________________________________________. The deviation is based on this court’s finding that application of the presumptive child support award under state regulations would be unjust or inappropriate in this case. The Court has considered the best interest of each child for whom the support award is being established or modified. The payments shall be made to the Clerk’s office together with the Clerk’s lawful fee ($_______) for a total payment of $__________ per __________, or to the central collection and disbursement unit in cases covered by T.C.A. §36-5-116 beginning on ___________________, 20_______. Said support shall be paid by income assignment. * Child Support Worksheet can be found on DHS website at http://www.state.tn.us/humanserv/is/incomeshares.htm or at your local child support offices. Revised 7-1-05 Page 2 of 4 American LegalNet, Inc. www.USCourtForms.com ______ Respondent shall pay $__________ per __________ for the support of petitioner, the payments to be made to the clerk’s office, together with the Clerk’s lawful fee ($_______), for a total payment of $__________ per __________ beginning on __________________________, 20_____. Said support shall be paid by income assignment. ______ Petitioner is awarded exclusive possession of the parties’ residence at _______________________ and respondent is evicted therefrom; ______ Respondent shall provide suitable alternate housing for the petitioner by ________________, 20___. ______ Respondent is prohibited from disconnecting utilities of joint residence. _______ Respondent is ordered to complete the following intervention program(s) for violence and control issues and/or substance abuse problems and shall report respondent’s attendance, participation, and progress in such intervention program(s): __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ ______ This order shall take effect immediately, pursuant to T.C.A. §36-3-609(c ), not withstanding when the order is entered, the protection of the petitioner requiring it. ______ Respondent is prohibited from possessing, shipping, receiving or transporting a firearm or ammunition while this order of protection is in effect. _______ Such other provisions as may be necessary to protect the petitioner and the petitioner’s minor child(ren): ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ IT IS FURTHER ORDERED that respondent shall pay the costs, attorney fees and litigation tax of this cause for which execution may issue. IT IS FURTHER ORDERED that this Order shall remain in effect for a period of one year, and petitioner, upon notice to respondent, may request a continuation of this Order. __________________________________ DATE _______________________________________________ JUDGE Approved for Entry: ________________________________ Petitioner/Petitioner's Attorney ________________________________ Respondent/Respondent's Attorney Return of Service Served on the respondent (check one) ____ by personal service OR ____ by mailing a copy to the respondent by U.S. mail postage prepaid to the respondent's last known address OR ____ the respondent's last known address is unknown and cannot be ascertained upon diligent inquiry OR ____ by mail in the manner as set forth in Tennessee Code Annotated §§20-2-215 and 20-2-216, the respondent being a non-resident of Tennessee on ____________________, 20________ at _________ a.m./p.m. Revised 7-1-05 _________________________________________ Clerk/Deputy Clerk/ Authorized Officer/Attorney Page 3 of 4 American LegalNet, Inc. www.USCourtForms.com WARNINGS TO RESPONDENT: This order shall be enforced, even without registration, by the courts of any state, the District of Columbia, any U.S. Territory, and may be enforced by Tribal Lands (18 U.S.C. Section 2265). Crossing state, territorial, or tribal boundaries to violate this order may result in federal imprisonment (18 U.S. C. Section 2262). In addition to the provisions of this order, Federal law provides penalties for possessing, transporting, shipping, or receiving any firearm or ammunition (18 U.S. C. Section 922g(8)). Only the Court can change this order. 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. If you violate this order, you may be guilty of a Class A misdemeanor punishable by up to 11 months, 29 days in jail and/or a fine of up to $2,500.00. 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. 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 ). NOTICE: The home and work addresses and telephone numbers, social security number, and any other information requested to be held confidential which could reasonably be used to locate the whereabouts of the petitioner shall be maintained as confidential by the records custodian of a utility service provider or government entity under the provisions of Tennessee Code Annotated section 10-7-504(a)(15) and (16), upon a copy of this Order of Protection being provided to the records custodian of the utility service provider or governmental entity maintaining the particular records sought to be held confidential. Revised 7-1-05 Page 4 of 4 American LegalNet, Inc. www.USCourtForms.com Order of Protection – Warnings to Respondent ADVERTENCIAS AL QUERELLADO ORDEN DE PROTECCIÓN Aun sin que sea registrada, esta orden puede hacerse cumplir en los tribunales de cualquier estado, del Distrito de Columbia, y de cualquier territorio de los Estados Unidos, y también en los territorios indígenas (artículo 2265 del Título 18 del Código de Leyes de los Estados Unidos). Si usted cruza fronteras estatales, territoriales o fronteras de los territorios indígenas con el objeto de violar esta orden, puede ser encarcelado en la penitenciaria federal (artículo 2262 del Título 18 del Código de Leyes de los Estados Unidos). Además de las disposiciones de esta orden, la ley federal establece penas contra el poseer, transportar, enviar o recibir armas de fuego o municiones (artículo 922(g)(8) del Título 18 del Código de Leyes de los Estados Unidos). Solamente el tribunal puede reformar esta orden. 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 usted viola esta orden, es posible que sea culpable de un delito menor, Clase A, punible con una pena de encarcelamiento que podría abarcar hasta 11 meses y 29 días, una multa de hasta $2,500.00, o ambas. 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. 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. AVISO: El encargado de los registros de cualquier proveedor de servicios públicos o de entidades gubernamentales preservará la confidencialidad del domicilio de la parte solicitante y de su dirección de trabajo, de sus números de teléfono, de su número de seguro social y de cualquier información adicional que se podría utilizar razonablemente para descubrir su paradero, a tenor de las disposiciones del Código Anotado de Leyes de Tennessee, en su artículo 10-7-504(15) y (16), cuando se presente copia de esta Orden de Protección al encargado antes mencionado que tenga bajo su custodia los registros particulares que se soliciten mantener en secreto. Revised 7-1-05 American LegalNet, Inc. www.USCourtForms.com