______________________________ 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. ) ) ) ) ) ) ) ) ) ) EX PARTE 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. The court having found that Petitioner is a person interested in the minor child/ren on whose behalf the Petition was brought, that Petitioner first made a referral to the Division of Child and Family Services, and that the Court has jurisdiction over this matter, has reviewed Petitioner's Verified Petition for Child Protective Order, from which it appears that the above-named child/ren is being or is in imminent danger of being physically or sexually abused, and pending further hearing in this matter, Approved Board of Juvenile Court Judge February 10, 2012 1 American LegalNet, Inc. www.FormsWorkFlow.com PURSUANT TO UTAH CODE SECTION 78B-7-204, THE PETITIONER IS GRANTED AN EX PARTE CHILD PROTECTIVE ORDER: (The Judge shall initial each section that is included in this Order.) _____ 1. The Respondent is restrained from attempting, committing, or threatening to commit abuse against the following child/ren 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 minor child/ren, 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 child/ren, and Respondent is prohibited from terminating or 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 child/ren. This includes any known subsequent school, place of employment, and/or other places frequented by the minor child/ren. The current addresses include: ________________________________________________________________________ ________________________________________________________________________ Approved Board of Juvenile Court Judge February 10, 2012 2 American LegalNet, Inc. www.FormsWorkFlow.com ________________________________________________________________________ ________________________________________________________________________ _____ 5. The Court having found that Respondent's use or possession of a weapon may pose a serious threat of harm to minor child/ren, the Respondent is prohibited from purchasing, using, or possessing a firearm or any of the following weapons:____________________________________________________ ________________________________________________________________________ _____ 6. effects: The minor child/ren are awarded possession of the following essential personal ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________. This award is subject to subsequent orders concerning the listed property in future proceedings. RESPONDENT'S VIOLATION OF "1" THROUGH "6" PROVISIONS OF THIS ORDER, IS A CLASS A MISDEMEANOR UNDER UTAH CODE SECTION 76-5-108. IF RESPONDENT'S VIOLATION OF PROVISIONS "1" THROUGH "6" OF THIS ORDER, IS A SECOND OR SUBSEQUENT DOMESTIC VIOLENCE OFFENSE, ENHANCED PENALTIES MAY BE IMPOSED UNDER UTAH CODE SECTIONS 7736-1.1 AND 77-36-2.4. THE COURT ORDERS THE FOLLOWING RELIEF IN THE CIVIL PORTION OF THIS EX PARTE PROTECTIVE ORDER: (The civil portion is effective from the date and time served on the Respondent, until, after further hearing, the Respondent is served with a protective order, the protective order is denied, or this matter is dismissed). VIOLATIONS OR FAILURE TO COMPLY WITH THE CIVIL PORTION, LISTED BELOW, MAY SUBJECT A PERSON TO CONTEMPT PROCEEDINGS. Approved Board of Juvenile Court Judge February 10, 2012 3 American LegalNet, Inc. www.FormsWorkFlow.com _____ 7. Temporary custody of the minor child/ren shall be as follows: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ _____ 8. The Respondent shall have parent-time as follows: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ______ 9. The Respondent is restrained from using drugs and/or alcohol prior to or during parent-time. ____ 10. Utah. The Respondent is restrained from removing the minor child/ren from the state of ____ 11. Support is ordered in accordance with Title 78B, Chapter 12, Uniform Liability for Sup