1 of 5 Request for Civil Stalking Injunction Case Number: District: County: State: Utah Judge: Petitioner (person needing protection) : First Name Middle Last Address and phone # (to keep private, leave blank): Street City --- State --- Zip Phone # Pet (if an y): Phone # If you are under 16 years old, have you ever been married or emancipated by a court? [ ] Yes [ ] No Respondent (person you need to be protected from): First Name Middle Last Other names used: Address : Street --- Cit y --- State Zip A judge can grant a stalking injunction only if the Respondent did any of the following towards you two or more times, in a manner that would cause a reasonable person to suffer emotional distress or to be afraid for the person's own safety or the safety of someone else: a.The Respondent directly, indirectly, or through someone else followed, monitored, observed,photographed, surveilled, threatened, communicated to you, or about you, or interfered with yourproperty using any action, method, device, or means; orAmerican LegalNet, Inc. www.FormsWorkFlow.com The Respondent and I have the following minor Children: Name Age Approved by Board of District Court Judges, June 2013 Revised December 31, 2018 2 of 5 you to a family member, household member, employer, co-worker, friend, or associate; v.placed an object on or delivered an object to property owned, leased, or occupied by you or to yourplace of employment with intent that the object be delivered to you; orvi.used a computer, the Internet, text messaging, or any other electronic means.For a complete definition of stalking, see Utah Code Sect 76-5-106.5 and 77-3a-101- 103. Note! In addition to your own statements in this Request, you must provide some other evidence of stalking, like police reports, sworn statements from witnesses, audio or video tapes, other records, photos, letters, etc. 3 Provide as much information as you can about the Respondent. (Name and address): Best place and time to find the Respondent: (Place): (Time): Other addresses (hangouts): : Year: Color: License Plates: If more than one vehicle, describe here: Make: Year: Color: License Plates: : Has the Respondent used weapons or been violent in the past? [] Yes [] No [] Is the Respondent a law enforcement officer, government investigator, or licensed private investigator? [] Yes [] No [] 4 Describe the stalking below: a.When and where did the stalking events happen? (Attach additional pages if necessary.)1st stalking event:When: Where: 2nd stalking event: When: Where: Other stalking events: When: Where: b.Who did you report the stalking to (if anyone)? c.List names of all people who witnessed the stalking: American LegalNet, Inc. www.FormsWorkFlow.com Approved by Board of District Court Judges, June 2013 Revised December 31, 2018 3 of 5 d.List any evidence you have of the stalking, like transcripts, audiotapes, police reports, photos, swornstatements from witnesses (affidavits), etc. You must attach at least one of these to this form.e.Describe what the stalker did and why it would have made a reasonable person feel emotionallydistressed, afraid of being physically harmed, or afraid that someone else would be physically harmed:f.Other facts: [] Check here if you need more space and attach additional sheets as needed. 5 Other Court Cases a.Are there other Court orders to the Respondent about stalking? [] Yes [] No(If Yes, fill out below and attach a copy of the court order.)b.Have you or the Respondent ever been involved in any other court case involving either of you?[] Yes [] No (If yes, list ALL court cases below): American LegalNet, Inc. www.FormsWorkFlow.com Approved by Board of District Court Judges, June 2013 Revised December 31, 2018 4 of 5 Type of Case County and State Court Case # (NOT the police report #) Person involved Did the judge make an order? [] You [] Respondent [ ] Yes [] No [] You [] Respondent [] Yes [] No [] You [] Respondent [] Yes [] No [] You [] Respondent [] Yes [] No I am asking the Court to make the orders I have checked below. 6 [] Personal Conduct Order the Respondent not to stalk me. 7 [] No Contact Order the Respondent not to contact or communicate with me or any person listed below, either directly or indirectly, by phone, text, mail, email, or any other way: Name Relationship to Petitio ner Address 8 [] Stay Away Order the Respondent to stay away from: [] a. My current or future: [] Vehicle [] Job [] School [] Home, premises and property (My current addresses are listed below): Home address: Work address: School address: Describe vehicle: [] b. Other (specify): 9 [] Child Custody & Parent-Time Orders Give me custody of the minor children listed here Give the Respondent parent-time as follows Name someone who can communicate parent-time information to the Respondent: American LegalNet, Inc. www.FormsWorkFlow.com Approved by Board of District Court Judges, June 2013 Revised December 31, 2018 5 of 5 10 [] Other Assistance Needed (List below any other orders needed to protect you and the other protected people listed on page 1 of this form): The Petitioner must read and sign below: I swear that: I am the Petitioner and I have read this Request for Civil Stalking Injunction,I am a victim of stalking and I believe the Respondent is the stalker, andI live in this county or the Respondent lives in this county, or the stalking took place in this county. I declare under criminal penalty under the law of Utah that everything stated in this document is true . Signed at (city, and state or country). Sign atu Date Printed Name If the Petitioner is a minor, then a parent or guardian must sign below. I swear that: Request for Civil Stalking Injunction,Petitioner is a victim of stalking and I believe the Respondent is the stalker, andThe Petitioner lives in this county or the Respondent lives in this county, or the stalking took placein this county. I declare under criminal penalty under the law of Utah that everything stated in this document is true . Signed at (city, and state or country). Parent or Guardian's Sign atu re Date Parent or Guardian's Printed Name American LegalNet, Inc. www.FormsWorkFlow.com Approved by Board of District Court Judges, June 2013 Revised December 31, 2018