Ex Parte Order of Protection Amended Order Case No. Court County Tennessee PETITIONER/PLAINTIFF First Middle Last PETITIONER/PLAINTIFF IDENTIFIERS Date of Birth of Petitioner V. RESPONDENT First Middle RESPONDENT IDENTIFIERS SEX RACE DOB HT WT Last EYES Relationship to Petitioner HAIR SOCIAL SECURITY # Address & Phone No. Distinguishing Features Respondent’s Employer CAUTION: Weapon Involved 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 domestic abuse against the petitioner or petitioner’s minor children; 2. That you shall not telephone, contact, or otherwise communicate with the petitioner, directly or indirectly; 3. That you shall not stalk the petitioner, as defined in TCA § 39-17-315; 4. That if you violate this order, you may be held in contempt of Court and punished by incarceration and/or a fine; 5. 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; 6. That, pursuant to Tennessee Code Annotated § 36-3-609, a copy of this order be issued to all local law enforcement agencies in County; 7. 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. DATE JUDGE/MAGISTRATE Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com 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. 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 PENTALY OF UP TO $50.00 FOR EACH VIOLATION PURSUANT TO T.C.A. § 36-3610. DATE OF HEARING ________________________ AT ____________________ A.M./P.M. PLACE OF HEARING _______________________________________________________ OFFICER’S RETURN Served on respondent by [check one] _____ personally reading the Order to respondent and by leaving a copy of the Order with respondent, 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] Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com