Case Number:_______________ District:_____ 
County:_____________________________   State: Utah 
Judge:  __________________________________________  
Commissioner: __________________________________   

Other people protected by this order  

Name 

Age 

Relationship to 
Petitioner 

 
 
 
 
 

 

 
 

 

 

 
 
   
 
 
 
 
   
 
 
 
 

Phone # 

 
 
 
 
 

 
 
 
 
 

 

Middle  

First  
Address and phone # (to keep private, leave blank): 
 
  Street 

Last 

 

 
  City  

Phone #:  

State 

Zip 

Petitioner’s attorney (if any):  
 

Name 

Respondent (person Petitioner is protected from) 
 

emporary Dating Violence 

Protective Order 
Ex Parte Order  

etitioner (protected person)  

  T

  P

 

First  
Other names used:  
Address (street):  

Middle  

Last 

Eyes 

Hair 

State               Zip 

Describe Respondent: 

  Sex 
 

 

 

Race  Date of Birth 

Ht 
 

Wt 

 

Social Security # 
(only the last 4 numbers) 
 

 

 
  Distinguishing features (like scars, tattoos, limp, etc.):  

 

 
Driver’s license issued by (State): 

 Expires:  

 

Warning!   [____]  Weapon involved (Box to be initialed by Court, if applicable) 

indings: Based upon the allegations contained in the request for a protective order the Court finds: 
1.  The Court has jurisdiction over the parties and this dispute. 
2.  The Petitioner and the Respondent are dating partners as defined by statute. 
3.  (check those that apply) 

_____ The Respondent has abused or committed dating violence against the Petitioner, or 
_____  There  is  a  substantial  likelihood  that  the  Respondent  will  commit  abuse  or  dating  violence 
against the Petitioner.  

 

 
 
 
 
 

 

 

 

 
 
 
 

 

 

 

 
 

 

 

he Court Orders: 

To: (Respondent’s Name): ______________________________________ 

Appear at the hearing on  
Date: _______________________ Time: _____________  
before (Judicial Officer): ____________________________ 
Address: __________________________________________   
Courtroom: __________________ 

 
City 

 

  F

  T

1 

Approved Board of District Court Judges June 
20, 2014 / Revised by Forms Committee April 
11, 2022 
 

 

Temporary Dating Violence Protective Order 

Page 1 of 4 

2 

[     ] 

Personal Conduct Order   Do not commit, try to commit or threaten to commit any form of 
violence or abuse 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 
violence or abuse.  

3 

[     ] 

No Contact Order   Do not directly or indirectly contact, phone, text, mail, e-mail, or 
communicate in any way with the Petitioner or any person listed on page 1 of this form.  

4 

[     ] 

Stay Away Order    

[  ]  Respondent is ordered to stay at least ___________ feet from petitioner. 

[  ]  Respondent is ordered to stay away from: 

[  ]  Petitioner’s home: 

___________________________________________________________________ 
(Street, City, State, ZIP) 

[  ]  Petitioner’s work:  

___________________________________________________________________ 
(Street, City, State, ZIP) 

[  ]  Respondent works at the same place as the petitioner. Respondent is not 
ordered to stay away from this location, but the following restrictions apply 
when petitioner and respondent are both there:    

 

 

[  ]  Petitioner’s school:  

___________________________________________________________________  
(Street, City, State, ZIP) 

[  ]  Respondent attends the same school as the petitioner. Respondent is not 
ordered to stay away from this location, but the following restrictions apply 
when petitioner and respondent are both there:  

[  ]  These places, which the petitioner goes to often: 

______________________________________________________________ 
(Name of place, Street, City, State, ZIP) 

______________________________________________________________ 
(Name of place, Street, City, State, ZIP) 

[  ]  These places, which the people listed on page 1 go to often:  

Name of person 

Description of place and 
address  
(Street, City, State, ZIP) 

 

 

 

Approved Board of District Court Judges June 
20, 2014 / Revised by Forms Committee April 
11, 2022 
 

 

Temporary Dating Violence Protective Order 

Page 2 of 4 

 

  [___] 

No Harming Pets   Do not physically injure or threaten to injure a pet that is: 
[  ] a.  Owned or kept by the Petitioner. Do not take possession of the Petitioner’s pet.  

[  ] b.  Owned or kept by you. 

Other:  __________________________________________________________________ 
6  [     ] 
                          _______________________________________________________________________________ 

Service:   The Court directs that the Respondent be served notice of his/her opportunity to be 
heard at a scheduled hearing. 

arnings to the Respondent:  

•  This order lasts until the hearing noted above (unless extended by the Court). 
•  This is a Court order. No one except the court can change it. You can tell your side when you 
get to court. If you do not obey this order, you can be arrested, fined, and face additional 
charges. 

•  A violation of this order is a Class A Misdemeanor punishable by up to 364 days in jail and a 

fine. 

• 

If you fail to appear at the scheduled hearing your default will be noted and the Court may 
make additional orders or make these orders permanent without further input from you. 
•  This order is valid in all states and territories of the United States, the District of Columbia 
and tribal lands. If you go into another state, territory or tribal land to violate this order a 
federal judge can send you to prison. 

Approved Board of District Court Judges June 
20, 2014 / Revised by Forms Committee April 
11, 2022 
 

Temporary Dating Violence Protective Order 

Page 3 of 4 

 

 

  W

   

  5

 

 

  7

 

 

 

Name of person 

Description of place and 
address  
(Street, City, State, ZIP) 

 

Name of person 

Description of place and 
address  
(Street, City, State, ZIP) 

 

 

 

 

[  ]  Other (specify):  

 

Attendance  
You must attend. If you do not attend, you 
might be held in contempt of court and the 
relief requested might be granted. You have 
the right to be represented by a lawyer. 

Asistencia 
Presentarse es obligatorio. Si usted no llegara 
a presentarse, se lo podría encontrar en 
desacato de las órdenes del juez y la 
reparación solicitada podría ser otorgada. 
Usted tiene el derecho de que lo represente un 
abogado. 

Evidence  
Bring with you any evidence that you want 
the court to consider. 

Pruebas  
Traiga con usted cualquier prueba que quiera 
que el tribunal tome en cuenta. 

Interpretation  
If you do not speak or understand English, 
the court will provide an interpreter. Contact 
court staff immediately to ask for an 
interpreter.  

Interpretación  
Si usted no habla ni entiende el Inglés el 
tribunal le proveeré un intérprete. Contacte a 
un empleado del tribunal inmediatamente para 
pedir un intérprete. 

ADA Accommodation  
If you need an accommodation, including an 
ASL interpreter, contact court staff 
immediately to ask for an accommodation. 

Finding help 
The court’s Finding Legal Help web page 
(www.utcourts.gov/howto/legalassist/) 
provides information about the ways you can 
get legal help, including the Self-Help 
Center, reduced-fee attorneys, limited legal 
help and free legal clinics. 

Adaptación o Arreglo en Caso de 
Discapacidad  
Si usted requiere una adaptación o arreglo, 
que incluye un intérprete de la lengua de 
signos americana, contacte a un empleado del 
tribunal inmediatamente para pedir una 
adaptación. 

Cómo encontrar ayuda legal 
La página de la internet del tribunal Cómo 
encontrar ayuda legal 
(www.utcourts.gov/howto/legalassist/index-
sp.html/) tiene información sobre algunas 
maneras de encontrar ayuda legal, incluyendo 
el Centro de Ayuda de los Tribunales de Utah, 
abogados que ofrecen descuentos u ofrecen 
ayuda legal limitada, y talleres legales 
gratuitos. 

ommissioner's or Judge’s signature may instead appear at the top of the first page of this document. 

Approved Board of District Court Judges June 
20, 2014 / Revised by Forms Committee April 
11, 2022 
 

Temporary Dating Violence Protective Order 

Page 4 of 4 

Signature ► 

Commissioner 

Signature ► 

Judge 

 

 

 

 

  C

 
Date 

 
Date