______________________________ Petitioner’s Name ______________________________ Address (may be omitted for privacy) ______________________________ City, State, ZIP ______________________________ Telephone (may be omitted) IN THE _____________________DISTRICT JUVENILE COURT _____________________ COUNTY, STATE OF UTAH ____________________________, ) ) ) ) ) ) ) ) ) Petitioner, vs. ____________________________, Respondent. CHILD PROTECTIVE ORDER Case No. Judge NOTICE TO RESPONDENT: YOU CAN BE ARRESTED FOR VIOLATING THIS ORDER EVEN IF ANY PERSON PROTECTED BY THE ORDER INVITES OR ALLOWS YOU TO VIOLATE THE ORDER’S PROHIBITIONS. ONLY THE COURT CAN CHANGE THE ORDER. YOU MAY BE HELD IN CONTEMPT FOR IGNORING OR ALTERING THE TERMS OF THE ORDER. NOTICE TO PETITIONER: YOU CANNOT WAIVE, ALTER, IGNORE, OR DISMISS THIS ORDER WITHOUT FURTHER COURT ACTION. YOU MAY BE HELD IN CONTEMPT FOR IGNORING OR ALTERING THE TERMS OF THIS ORDER. This matter came for hearing on ___________________. The following parties were in attendance: 9 Petitioner 9 Petitioner’s attorney ____________________________ 9 Respondent 9 Respondent’s attorney __________________________ 9 Guardian ad Litem __________________________ 1 4/06 American LegalNet, Inc. www.FormsWorkflow.com The Court has reviewed Petitioner’s Verified Petition for Child Protective Order and: ___ has received argument and evidence, ___ has accepted the stipulation of the parties ___ has entered the default of the Respondent for failure to appear. The Court finds that the above-named minor has been or is in imminent danger of being physically or sexually abused therefore THE PETITIONER IS GRANTED A CHILD PROTECTIVE ORDER PURSUANT TO UTAH CODE SECTION 78-3h-104: (The Judge or Commissioner shall initial each section that is included in this Order.) _____ 1. Upon finding that Respondent presents a credible threat to the safety of minor child(ren), the Respondent is restrained from attempting, committing, or threatening to commit abuse against the following children, and shall not stalk, harass, or threaten to use or attempt to use physical force that would reasonably be expected to cause physical injury to the child(ren): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _____ 2. The Respondent is prohibited from harassing, telephoning, contacting, or otherwise communicating with the children, directly or indirectly: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _____ 3. The Respondent shall be excluded and is ordered to stay away from the residence and its premises located at: ___________________________ and any known subsequent residence of the minor children, and Respondent is prohibited from terminating or 2 4/06 American LegalNet, Inc. www.FormsWorkflow.com interfering with the utility services to the residence. _____ 4. The Respondent is ordered to stay away from the school, place of employment, and/or other places, and their premises, frequented by the minor children. This includes any known subsequent school, place of employment, and/or other places frequented by the minor children. The current addresses include: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _____ 5. Under state law pursuant to this order, the Court finds that Respondent’s use or possession of a weapon may pose a serious threat of harm to children. The Respondent is prohibited from purchasing, using, or possessing a firearm and/or the following weapon(s): ________________________________________________________________________ ________________________________________________________________________ _____ 6. The children are awarded possession of the following essential personal effects: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________ 3 4/06 American LegalNet, Inc. www.FormsWorkflow.com This award is subject to orders concerning the listed property in future proceedings. 7. An officer from the following law enforcement agency _____________________ is hereby directed and authorized to render any necessary assistance to the above-named petitioner in retrieving the child(ren) named in this Protective Order and give physical custody of said child(ren) __________________________________________________________________ ______________________________________________________ to the petitioner. Such action includes, but is not limited to, obtaining access to the child(ren) through locked doors and gates and restraining any persons who may attempt to prevent the removal of said child(ren). 8. An officer from the following law enforcement agency:____________________ ______________________________________________________ shall accompany the children to ensure that they safely regain possession of the property. 9. An officer from the same law enforcement agency shall facilitate Respondent’s removal of Respondent’s essential personal belongings from the parties’ residence. The law enforcement officer shall contact Petitioner to make these arrangements. Respondent may not contact the Petitioner or enter the residence to obtain any items. RESPONDENT’S VIOLATION OF PROVISIONS “1” THROUGH “9” OF THIS ORDER IS A CLASS A MISDEMEANOR UNDER UTAH CODE SECTION 76-5-108. IF RESPONDENT’S VIOLATION OF PROVISIONS “1” THROUGH “9” OF THIS ORDER IS A SECOND OR SUBSEQUENT DOMESTIC VIOLENCE OFFENSE, ENHANCED PENALTIES MAY BE IMPOSED UNDER UTAH CODE SECTIONS 77-361.1 AND 77-36-2.4. The following temporary relief (provisions “a” through “i”) is granted, which relief will (expire/be reviewed by the court) 150 days from the date of this order: 4 4/06 American LegalNet, Inc. www.FormsWorkflow.com _____ a. The Petitioner is granted custody of the following children: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________ _____b. Parent-time shall be as follows: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________. The Respondent is restrained from using drugs and/or alcohol prior to or during parent-time. _____ c. The Respondent is restrained from removing the children from the state of Utah. _____ d. The Respondent is ordered to pay child support in the amount of $_____________ pursuant to the Utah Uniform Child Support Guidelines. _____ e. The Respondent is ordered to participate in mandatory income withholding pursuant to Utah Code Annotated § 62A-11, Parts 4 and 5. _____ f. The Respondent is ordered to pay one-half of the children’s day care expenses. _____ g. The Respondent is ordered to pay one-half of the minor child/ren’s medical expenses including premiums, deductibles and co-payments. 5 4/06 American LegalNet, Inc. www.FormsWorkflow.com _____ h. The Respondent is ordered to pay the minor child/ren’s medical expenses, suffered as a result of the abuse in the amount of $________________________. _____ i. Other:____________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Notice to Petitioner: if at any time, you receive services through the Office of Recovery Services, and you want to keep your location information confidential, you must provide a copy of your current protective order to ORS. Violation of provisions “a” through “i” may subject Respondent to contempt proceedings. _____10. The Division of Child and Family Services shall provide information to the Court as to the status of Petitioner’s referral. _____11. A guardian ad litem is appointed to represent the best interests of the children. _____12. Law enforcement agencies with jurisdiction over the protected locations shall have authority to compel Respondent’s compliance with this Order, including the authority to forcibly evict and restrain Respondent from the protected areas. Information to assist with identification of the Respondent is attached to this Order. ____ 13. Under federal law, the Respondent may be prohibited from purchasing, owning, transporting, using or possessing a firearm and ammunition. There is an exemption for police and military personnel while on actual duty and those persons need to contact their immediate 6 4/06 American LegalNet, Inc. www.FormsWorkflow.com supervisors for further instructions regarding compliance with federal law. 14. Respondent was afforded both notice and opportunity to be heard in the hearing that gave rise to this order. Pursuant to the Violence Against Women Act of 1994, P.L. 103-322, 108 Stat. 1976, 18 U.S.C.A. 2265, this order is valid in all the United States, the District of Columbia, tribal lands, and United States Territories. This order complies with the Uniform Interstate Enforcement of Domestic Violence Protection Orders Act. 15. Two years after the date of this order, Respondent can request a hearing to dismiss the criminal provisions of the order. Within 30 days prior to the end of the two-year period, the Petitioner should provide the court with a current address, which address will not be made available to Respondent. The civil portion of the order will expire or be reviewed 150 days after the pretrial hearing. PETITIONER MAY PROVIDE A COPY OF THIS ORDER TO THE CHILD/REN’S SCHOOL PRINCIPAL. PETITIONER MAY ENFORCE A COURT ORDER IF RESPONDENT VIOLATES OF FAILS TO COMPLY WITH PROVISION(S) OF THIS ORDER. DATED: _____________________. BY THE COURT: ____________________________________ JUVENILE COURT JUDGE 7 4/06 American LegalNet, Inc. www.FormsWorkflow.com By this signature, Respondent approves the form, and accepts service of this Protective Order and waives the right to be personally served. _____________________________ Respondent Serve Respondent at: Name: __________________________________ Street: __________________________________ City/Town: __________________________________ State, Zip: __________________________________ Serve Parent or Guardian: Name: __________________________________ Street: __________________________________ City/Town: __________________________________ State, Zip: __________________________________ Serve Guardian ad Litem: Name: __________________________________ Street: __________________________________ City/Town: __________________________________ State, Zip: __________________________________ 8 4/06 American LegalNet, Inc. www.FormsWorkflow.com