Case No. Order of Protection Amended Order Court County Tennessee PETITIONER/PLAINTIFF First Middle Last PETITIONER/PLAINTIFF IDENTIFIERS Date of Birth of Petitioner V. RESPONDENT IDENTIFIERS SEX RACE DOB RESPONDENT First Middle HT WT Last EYES Relationship to Petitioner HAIR SOCIAL SECURITY # Address & Phone No. Distinguishing Features Respondent’s Employer CAUTION: Weapon Involved 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 or threats of abuse 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 , . 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). 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. Page 1 of 3 American LegalNet, Inc. www.USCourtForms.com THE COURT FURTHER FINDS AS FOLLOWS: That the 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 or threaten to commit domestic abuse against the petitioner or the petitioners’ minor child(ren); or use or threaten physical force that would reasonably be expected to cause bodily injury; or stalk the petitioner, as defined in T.C.A. §39-17-315. (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 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 $___________ per __________ for the support of the parties’ minor child(ren), the payments to be made to the Clerk’s office together with the Clerk’s lawful fee ($_______) 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. _______ 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 _________________________ and respondent is evicted therefrom; the parties’ residence at Respondent shall provide suitable alternate housing for the petitioner by ______________________, 20______. _______ 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): ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Page 2 of 3 American LegalNet, Inc. www.USCourtForms.com _______ (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 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 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. §36-3-610. 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 under the provisions of Tennessee Code Annotated, Section 10-7-504(15), and may be maintained as confidential by the records custodian of a governmental entity under the provisions of Tennessee Code Annotated, Section 10-7-504(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. RETURN OF SERVICE Served on the respondent, a resident of Tennessee, by personally reading the order to the respondent and by leaving a copy of the order with the respondent, on ________________________, 20________ at ________ a.m./p.m. OR ALTERNATIVELY: Served on the respondent, a non-resident of Tennessee, by mail in the manner as set forth in Tennessee Code Annotated §§20-2-215 and 20-2-216, on _________________________, 20________ at _________ a.m./p.m. _________________________________________ Clerk/Deputy Clerk or Authorized Officer Revised 8/21/03 Page 3 of 3 American LegalNet, Inc. www.USCourtForms.com