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Verified Petition For Exparte Child Protective Order Form. This is a Utah form and can be use in Protective Orders And Civil Stalking Statewide.
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Tags: Verified Petition For Exparte Child Protective Order, Utah Statewide, Protective Orders And Civil Stalking
____________________
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.
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VERIFIED PETITION FOR
EXPARTE CHILD
PROTECTIVE ORDER
Civil No.
Judge:
PETITIONER IS ADVISED THAT KNOWING FALSIFICATION OF ANY STATEMENT
OR INFORMATION PROVIDED FOR THE PURPOSE OF OBTAINING A PROTECTIVE
ORDER MAY SUBJECT THE PETITIONER TO FELONY PROSECUTION. (Utah Code Ann.
Section 78-3h-107)
G
Petitioner made a referral of abuse to the Division of Child and Family Service
within the previous 30 days based upon the incidents alleged in the petition.
The Petitioner alleges:
1.
Petitioner is seeking a protective order on behalf of the following child/ren:
NAME
BIRTH DATE
ADDRESS
(may be omitted for security
reasons, if omitted please
explain)
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2a.
The child/ren currently live with:
______________________________________________________________________________
______________________________________________________________________________
2b.
During the last six months the child/ren has lived with the following individual/s
at the following address/es (if different than above):
CHILD’S NAME
ADDRESS
(include name and dates)
3a.
LIVED WITH
(city/county/state only)
Petitioner is a person interested in the minor child/ren for the following reasons:
(Please describe your relationship to the child/ren and to the Respondent).
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3b.
Describe how the Respondent is related to the child/ren.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4.
Either Petitioner or Respondent resided in, or the acts occurred in, this County.
5.
On or about ______________, 20___, at_______________, Utah, the following
events occurred that Petitioner believes indicates that the child/ren is being abused or is in
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imminent danger of being abused. [Describe in detail what happened, when the events
occurred, where, who was involved (including the child/ren and family and household
members), if weapons were involved, and if injuries resulted. State the name and address
of any other person who may have witnessed the abuse. Attach more sheets if necessary
but only write on one side.]
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
6.
Check one:
G No cases of any type (divorce, custody, other protective orders, etc.) involving
Petitioner, Respondent and/or the others named in this petition have been filed in any court.
G The following cases which involve Petitioner, Respondent and/or the others named in
this petition have been filed, including the child/ren on behalf of whom Petitioner is seeking a
protective order. (List all cases that have been filed in any court, at any time):
Party
Filing Date or
Judgment Date
Court or County where Case
Filed
Case Number;
Case Type
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7.
Check one:
G Petitioner has not filed for a protective order in any other court of the State.
G Petitioner has filed for the following protective orders in another court of the
State: (List all protective order filings in any court, at any time):
Respondent; relationship to Date of filing
Petitioner
or judgment
Court or County
where case filed
Has a judge signed
an order?
WHEREFORE: I respectfully request that this Court:
_____ Order the Respondent to appear at a hearing.
_____ Order the Division of Child and Family Services to provide to the Court information
regarding the status of Petitioner’s referral.
_____ Immediately issue Ex Parte relief on the Child Protective Order and, after a hearing in 20
days, issue a Child Protective Order containing the following relief (Check boxes of relief that
you are requesting):
Q
Restrain the Respondent from attempting, threatening or committing abuse
against the minor children and designated family and household members and from
stalking, harassing, or threatening or using or attempting to use physical force that would
reasonably be expected to cause physical injury to the minor.
Q
Prohibit the Respondent from directly or indirectly contacting, harassing,
telephoning, e-mailing, or otherwise communicating with the minor children.
Q
Order the Respondent to vacate and stay away from the residence located at:
_________________________________________________________________, and
any subsequent residence of the minor children, and prohibit the Respondent from
terminating or interfering with the utility services to the residence.
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Q
Order the Respondent to stay away from the school, place of employment, and
other places, and their premises, frequented by the minor children and designated family
or household members, and any known subsequent school, place of employment or other
places frequented by the minor children and designated family or household members.
The current addresses include:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Q
Prohibit the Respondent from purchasing, using, or possessing a firearm or other
weapon as designated by the court, including:
________________________________________________________________________
________________________________________________________________________
Q
Award possession of the following personal property: ________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Q
Order a law enforcement officer to accompany Petitioner and the children to the
residence to ensure that the children are safely restored to possession of the listed items.
Q
Order a law enforcement officer to supervise Respondent’s removal of essential
personal belongings from the residence.
Appoint a Guardian ad Litem to represent the best interests of the children.
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_____
Include in the Protective Order the following temporary relief which should be in
effect for up to 150 days (explain in writing and attach if additional time will be necessary).
Q
Grant appropriate custody of the minor children.
Q
Order the following parent-time arrangement (if requesting parent-time arranged
through or supervised by another person, identify that person):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Q
Restrain Respondent from using drugs and/or alcohol prior to or during
parent-time.
Q
Restrain Respondent from removing the minor children from the state.
Q
Order Respondent to pay child support in the amount of $______________
pursuant to the Utah Uniform Child Support Guidelines.
Q
Order Respondent to participate in mandatory income withholding pursuant to
Utah Code Annotated § 62A-11, Parts 4 and 5.
Q
Q
Order Respondent to pay one-half of the minor child/ren’s day care expenses.
Order Respondent to pay one-half of the minor child/ren’s medical expenses
including premiums, deductibles and co-payments.
Q
Order Respondent to pay the minor children’s medical expenses suffered as a
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result of abuse in the amount of $_____________________.
Q
Order any other relief that the court considers necessary for the safety and welfare
of the children and designated household and family members, including the following:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
DATED: _____________________________.
State of Utah
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) ss:
____________ County
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Being sworn, I state that I am the Petitioner; that I have read this Petition and the statements in it
are true and correct to the best of my knowledge; that I believe I am entitled to the relief
requested, and that this Petition is not being used to harass or to abuse process.
_______________________________________
Petitioner
Subscribed and sworn to before me on ______________________________.
_______________________________________
Clerk or Notary Public
Residing at:
My Commission Expires:
Serve Respondent at:
Street:
__________________________________
City/Town:
__________________________________
State, Zip:
__________________________________
Serve Parent or Guardian:
Name:
__________________________________
Street:
__________________________________
City/Town:
__________________________________
State, Zip:
__________________________________
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Serve Guardian ad Litem:
Name:
__________________________________
Street:
__________________________________
City/Town:
__________________________________
State, Zip:
__________________________________
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