Request for Protective Order 1 Petitioner (person asking for protection ): First Middle Last This is a private record. Address and phone # (to keep private, leave blank): Other people protected by this order 000013000U000H000O000D000W000L000Y000H000V000003000R000U000003000S000H000R000S000O000H000003000Z000K000R000003000O000L000Y000H000003000Z000L000W000K000003000\000R000X000f000035 Street City --- State --- Zip Name 000003 000003 Age Relationship to Petitioner 2 Respondent Describe Respondent *Required. First Middle Last Other Names Used 000003 000+000D000L 000U 000003 000)000X000O000O000003 0006000R000F000L000D000O0000030006000H000F000X000U000L000W000\000003 000006 000003 000013 000L000I000003000N000Q000R000Z000Q 000f 000003 000003 000'000L000V000W000L000Q000J000X000L000V000K000L000Q000J000003000I000H000D000W000X000U000H000V000003 (like tattoos, scars, limp, etc.) 000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B 000B000B000B000B 000B000B 000003 City --- State --- Zip 000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B 000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B000B 000B000B000B000B 000B 000003 000'000U000L000Y000H000U000266000V000003000O000L000F000H000Q000V000H000003000L000V000V000X000H000G000003000E000\000003 (State) American LegalNet, Inc. www.FormsWorkFlow.com 3 What is your relationship to the Respondent? 4 Describe the most recent abuse : American LegalNet, Inc. www.FormsWorkFlow.com 5 Describe past abuse 6 Describe why you think there is a substantial likelihood that the Respondent will commit domestic violence or abuse 7 Other Court Cases American LegalNet, Inc. www.FormsWorkFlow.com Please, Judge, I am asking you to: XXX8 [] Personal Conduct American LegalNet, Inc. www.FormsWorkFlow.com 9 [] No Contact 10 [] Contact for Mediation only11 [] Stay Away American LegalNet, Inc. www.FormsWorkFlow.com (specify): 12 []No Guns or Weapons 13 [] Property Control (address):(describe): Orders 14-21 can last up to 150 days after the hearing.14 [] Property Control 15 [] Transfer Wireless Phone Number(s)16[]Child Custody & Parent-time Orders American LegalNet, Inc. www.FormsWorkFlow.com 17 [] No Alcohol or Drugs18 [] Supervised Visitation 19 [] Travel Restrictions 20 [] Child Support, Spousal Support and other Expenses -- (Utah Code 62A-11,Parts 4 and 5) 21 [] Other Assistance Needed (List below any other orders needed to protect you and other protected people listed on page 1 of this form):I also ask for these Orders to Agencies: 22 []Law Enforcement to Assist 23 [] Investigate Possible Child Abuse 24 [] Guardian for your children American LegalNet, Inc. www.FormsWorkFlow.com The Petitioner must read and sign below: I understand it is a serious crime to lie to get a Protective Order. American LegalNet, Inc. www.FormsWorkFlow.com