Case Number: ________________ District:_____ County: _______________________ State: Utah Judge: __________________________________ Commissioner:____________________________ Modified Protective Order Petitioner (protected person): Other people protected by this order First Middle Last Name Address and phone # (to keep private, leave blank): Relationship to Petitioner Age Street City State Zip Phone #: Petitioner’s attorney (if any): Name Phone # Describe Respondent: Respondent (person Petitioner is protected from): Sex First Middle Last Eyes Other names used: Relationship to Petitioner: Address (street): City Race Date of Birth Hair Ht Wt Social Security # (only the last 4 numbers) Distinguishing features(like scars, tattoos, limp, etc.) State Zip Driver’s license issued by (State): Expires: Warning! Weapon involved (Box to be initialed by Court, if applicable) There was a hearing on (date): . The Respondent was given notice and an opportunity to be heard in the hearing that gave rise to this order. The following people were present at the hearing: Petitioner Petitioner’s attorney (name): Respondent Respondent’s attorney (name): Other (name) The Court reviewed the Request for Modified Protective Order, has received evidence, and finds the original protective order listed immediately below should be modified. Utah Code 30-6-4.2 Temporary Protective Order, signed by this court on (date): Protective Order, signed by this court on (date): The Court orders the Respondent to obey all orders initialed on The criminal orders on page 2 do not this form and to not abuse or threaten to abuse anyone protected by this order. expire unless dismissed by the Court. Warnings: • This is a court order. No one except the court can change it. If you do not obey this order, you can be arrested, fined, and face other charges. • This order is valid in all U.S. states and territories, the District of Columbia, and tribal lands. If you go to another U.S. state, territory or tribal land to violate this order, a federal judge can send you to prison. • No guns or firearms! (See page 2, item 5.) Violence Against Women Act of 1994, 18 U.S.C. §§ 2265, 2262, 18 U.S.C. § 922(g)(8) Modified Temporary Protective Order 1 of 4 Approved by Board of District Court Judges, June 2006 Revised: January 2007 American LegalNet, Inc. www.FormsWorkflow.com The Respondent must obey all orders initialed by the judicial officer. If you do not obey orders 1 – 6 below, the court can send you to jail for up to 1 year and order you to pay a fine. A second or subsequent violation can result in more severe penalties. (Violation of orders 1 – 6 below is a criminal Class A misdemeanor. Utah Code §§ 30-6-4.2, 76-5-108, 77-36-1.1, 77-36-2.4) 1 Personal Conduct Order Do not commit, try to commit or threaten to commit any form of violence against the Petitioner or any person listed on page 1 of this form. This includes stalking, harassing, threatening, physically hurting, or causing any other form of abuse. 2 No Contact Order Do not contact, phone, mail, e-mail, or communicate in any way with the Petitioner, either directly or indirectly. 3 Contact for Mediation You are allowed to have contact with the Petitioner only during court mediation sessions for your divorce or custody case that are scheduled with a Court Qualified Mediator. 4 Stay Away Order Stay away from: a. The Petitioner’s current or future: Vehicle Job School Home, premises and property (list current addresses below): Home address: Work address: School address: b. The school or childcare of the children listed on page 1 of this form. (List current school and childcare addresses here): c. Other (specify): 5 No Guns or Other Weapons The Court finds that your use or possession of a weapon poses a serious threat of harm to the Petitioner. You cannot possess, have, or buy a gun or firearm or any of these weapons: See Utah Code 30-6-4.2(2)(d) Warning! It is a federal crime for you to have, possess, transport, ship, or receive any firearm or ammunition, including hunting weapons, while this protective order is in effect, even if 5 above is not initialed. 6 Property Orders Unless a judge makes a different order later, only the Petitioner can use, control and possess the following property and things, but cannot dispose of this property without court approval: a. Home at (address): ____________________________________________________________________________ b. Car, truck or other property (describe): __________________________________________________________________________________________________ Modified Temporary Protective Order 2 of 4 Approved by Board of District Court Judges, June 2006 Revised: January 2007 American LegalNet, Inc. www.FormsWorkflow.com You must obey orders 7 – 12 initialed by the judge. If you do not, you will be in contempt of court and may be punished. These orders will expire be reviewed by the court in __________ days. 7 Property Orders Do not interfere with or change the Petitioner’s phone, utility or other services. 8 Child Custody & Parent-time Orders The Petitioner (the protected person) will have custody of the minor children listed below. The Petitioner may give a copy of this order to the principal or director of the child’s school or daycare. If you do not obey the custody and parent-time orders listed here, the Petitioner may ask for the court’s help (such as an order to show cause for contempt): __________________________________________________ ___________________________________________________________________________________________________________ You will have parent-time as follows: _________________________________________________________________ ___________________________________________________________________________________________________________ If there is a “No Contact” order, you can communicate with the Petitioner only about parent-time matters through: ________________________________________________________________________________________ 9 No Alcohol or Illegal Drugs Do not use alcohol or illegal drugs before or during visitation 10 No Travel with Children Do not take the children listed above out of the state of Utah. 11 Child Support, Spousal Support and other Expenses The Respondent will: a. Pay $ ______ / month in guidelines child support. b. Have child support withheld from the Respondent’s earnings. (Utah Code § 62A-11, Parts 4 and 5) c. Pay $ ______ / month in spousal support. d. Pay 50% of the minor children’s childcare expenses. e. Pay 50% of the minor children’s medical expenses, including premiums, deductibles and co-payments. f. Pay $ _________ for the minor children’s medical expenses related to the abuse and $ __________ for the Petitioner’s medical expenses related to the abuse. 12 Other Orders (List below):__________________________________________________________ Orders to Agencies 13 Law Enforcement to Assist A law enforcement officer from: will enforce the orders checked below: a. Help the Petitioner gain and keep control over home, car or other personal belongings. b. Help the Petitioner obtain custody of the children. c. Help the Respondent or Petitioner remove essential personal belongings from the home. Warning to the Respondent: Do not go into the home or other protected places without the officer.. Law enforcement can evict you or keep you away from protected places, if needed. 14 Investigate Possible Child Abuse This matter will be referred to the Division of Child and Family Services for review and possible investigation of child abuse. Modified Protective Order 3 of 4 Approved by Board of District Court Judges, June 2006 Revised: January 2007 American LegalNet, Inc. www.FormsWorkflow.com To the Petitioner: In 2 years, the Respondent may ask the court to dismiss the orders on this page. If that happens, we will need your address so the court can give you notice. If your address changes, you must let the court know at least 30 days before the 2-year period ends on __ / __ / __ . If you receive services from the Office of Recovery Services (ORS) and want to keep your address confidential, you must give ORS a copy of your current Protective Order. — The Court fills out below — Date: ________________________ Commissioner (printed name): _______________________________________________ Date: ________________________ Judge (printed name) ________________________________________________________ — The Respondent fills out below — By signing here, the Respondent approves the form, and accepts service of this Modified Protective Order and waives the right to be personally served. Respondent’s Address Street Respondent’s Signature Modified Protective Order City State Zip __________________________________________________________________ 4 of 4 Approved by Board of District Court Judges, June 2006 Revised: January 2007 American LegalNet, Inc. www.FormsWorkflow.com