Protective Order Page 1 of 6 Protective Order Case Number: District: County: State: Utah Judge: Petitioner (protected person): Commissioner: First Name Middle Last Address and phone # (to keep private, leave blank): Other people protected by this order Street Relationship to Petitioner Cit y --- State --- Zip Phone # : Respondent Describe Respondent (person Petitioner is protected from): Sex Race Date of Birth Ht. Wt. First Name Middle Last Other Names Used Eyes Hair Social Security # (only the last 4 numbers) Relationship to Petitioner: Address (street): Distinguishing features (like scars, tattoos, limp, etc.) City --- State --- Zip (State): Expires: Phone Number: 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 attorney (name): [] Respondent (name): [] Other (name) American LegalNet, Inc. www.FormsWorkFlow.com Name Age Approved Board of District Court Judges May 21, 2008 Revised December 31, 2018Protective Order Page 2 of 6 The Court reviewed the Request for Protective Order and [] received argument and evidence, [] accepted the stipulation of the parties, [] entered the default of the Respondent for failure to appear, finds that domestic violence or abuse has occurred or there is substantial likelihood of immediate danger of abuse or domestic violence by the Respondent, [] finds that a minor child witnessed the abuse or domestic violence, and makes the orders initialed below. The Court orders the Respondent to obey all orders initialed on this form and to not abuse or threaten to abuse anyone protected by this order. O rders 1 - 6 do not 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 bearrested, 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 goto another U.S. state, territory or tribal land to violate this order, a federal judge can send you toprison.No guns or firearms! (See page 3, item 5.)Violence Against Women Act of 1994, 18 U.S.C. 2265, 2262, 18 U.S.C. 922(g)(8) 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. 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 during Mediation -- You are allowed to have contact with the Petitioner only during mediation sessions for your divorce or custody case that are scheduled with a Court Qualified Mediator. 4 [] Stay Away Order -- Stay away from: [] a.premises and property (list current addresses below):Home address: Work address: School address: Vehicle description: American LegalNet, Inc. www.FormsWorkFlow.com Approved Board of District Court Judges May 21, 2008 Revised December 31, 2018Protective Order Page 3 of 6 [] b.The school or childcare of the children listed on page 1 of this form. (List currentSchool/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: Warning! If a final protective order is issued against you after the hearing, you will then become subject to the federal law making it a crime to possess, transport, ship or receive any firearm or ammunition, including a hunting weapon. 6 [] Property Orders -- Until further court order, 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): 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 -- services. 8 [] Child Custody & Parent-time Orders -- The Petitioner (the protected person) will have temporary custody of the minor children listed below. The Petitioner may give a copy of this and parent-order to show cause for contempt): You will have parent-time as follows: American LegalNet, Inc. www.FormsWorkFlow.com Approved Board of District Court Judges May 21, 2008 Revised December 31, 2018Protective Order Page 4 of 6 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 Utah. 11 [] Child Support, Spousal Support and other Expenses -- The Respondent will: [] a. Pay $ / month in child support. [] b. gs. (Utah Code 62A-11,Parts 4 and 5) [] c. Pay $ / month in spousal support. [] d. [] e. Pay deductibles and co-payments. [] f. Pay abuse and 12 [] Other Assistance Needed (List below any other orders needed to protect you and other protected people listed on page 1 of this form): 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. American LegalNet, Inc. www.FormsWorkFlow.com Approved Board of District Court Judges May 21, 2008 Revised December 31, 2018Protective Order Page 5 of 6 ng, medications, jewelry, a job or go to school. 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. NOTICE TO PETITIONER: The court may amend or dismiss a protective order after one year if it finds that the basis for the issuance of the protective order no longer exists and the petitioner has repeatedly acted in contravention of the protective order provisions to intentionally or knowingly induce the respondent to violate the protective order, demonstrating to the court that the petitioner no longer has a reasonable fear of the respondent. 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. 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. 1796, 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. The Court fills out below Judge or commissioner Date Commissioner Date Judge American LegalNet, Inc. www.FormsWorkFlow.com Approved Board of District Court Judges May 21, 2008 Revised December 31, 2018Protective Order Page 6 of 6 The Respondent fills out below By signing here, the Respondent approve