Affidavit for Filing an Out - o f - State Protective Order Approved Board of District Court Judges May 21, 2008 Revised February 6, 2019 Page 1 of 2 Affidavit for Filing an Out - of - State Case Number : County : District: State: Utah Protective Order Judge: Commissioner: Petitione r (person asking for protection): This is a private record. First Name Middle Last Other people protected by this order (relatives or people who live with you): Address and phone # (to keep private, leave blank): Name Age Relationship to Petitioner Street City --- State --- Zip Phone # s Respondent (person you need to be protected f rom): First Name Middle Last Address Street City --- State --- Zip Phone Number I swear that: I have attached a certified copy of a protective order issued in (State): To the best of my knowledge, the Respondent was personally served a copy of this order. To the best of my knowledge, the protective order is now valid, as written. American LegalNet, Inc. www.FormsWorkFlow.com Affidavit for Filing an Out - o f - State Protective Order Approved Board of District Court Judges May 21, 2008 Revised February 6, 2019 Page 2 of 2 es-ES Sign atu Date Petitioner s Printed Name On this date, I certify that (name) who is known to me or who presented satisfactory identification, in the form of (form of identification) , has, while in my presence and while under oath or affirmation, voluntarily signed this document and declared that it is true . Sign atu Date P rinted name (Court Clerk or Notary Public) Notary Seal es-ES American LegalNet, Inc. www.FormsWorkFlow.com