This is a private record. 

I am   [  ]  Petitioner         [  ]  Petitioner’s Attorney     (Utah Bar #:__________) 

In the District Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

_____________________________________ 
Petitioner (person asking for protection) 

Request for Sexual Violence 
Protective Order 
(Utah Code 78B-7-501 et seq.) 

_____________________________________ 
Respondent 

_______________________________ 
Case Number 

_______________________________ 
Judge 

_______________________________ 
Commissioner 

1. 

(Choose one.) 

[  ]  I am 18 or older. 

[  ]  I am under 18 and have been emancipated by marriage or court order. 

I am not a cohabitant of the respondent. 

I am not a dating partner of the respondent. 

Description of abuse 
(Utah Code 76-5-401 et seq., 76-5b-201 et seq., 76-5-308, 76-5-310) 

The respondent has committed or has tried to commit sexual violence against 
me.  

1201POF Approved May 13, 2019 
 

Request for Sexual Violence Protective Order 

Page 1 of 6 

v. 

2. 

3. 

4. 

ddress (omit if safeguarded) 

ity, State, Zip (omit if safeguarded) 

hone (omit if safeguarded) 

mail (omit if safeguarded) 

 
Name 

  A

  C

  P

  E

Sexual violence includes: 

•  Rape 
•  Object rape  
•  Sodomy 
•  Forcible sodomy 
•  Forcible sexual abuse 
•  Aggravated sexual assault 
•  Custodial sexual relations 
•  Custodial sexual misconduct  
• 

Indecent liberties 

 

•  Sexual exploitation of a vulnerable 

adult or a child 

•  Distribution of an intimate image  
•  Sexual extortion  
•  Human trafficking for forced 

sexual exploitation  

•  Aggravated human trafficking for 

forced sexual exploitation 

5. 

Describe the most recent sexual violence involving the respondent: 

a.  When did it happen? (Date.): _______________________________________ 

b.  Where did it happen? (Street, city and state.):  

 

______________________________________________________________ 

c.  Describe the sexual violence (Attach additional sheets if needed.): 

d.  Did the police come?    [  ] Yes    [  ] No 

e.  If the police came, 

•  Which police department came? _____________________________________ 

•  Was anyone arrested? [  ] Yes    [  ] No 

If yes, who was arrested? ___________________________________________ 

•  Provide police case number if known: ___________________________ 

f.  Did respondent use or threaten to use a gun or other weapon?    

[  ] Yes    [  ] No  (If yes, describe the weapons the respondent owns and how they were 

used against you.): 

1201POF Approved May 13, 2019 
 

Request for Sexual Violence Protective Order 

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g.  Have charges been filed in any court?  

[  ] Yes. 

  Court case number (if known): ____________________________________ 

Court name (for example, Sanpete District Court, Taylorsville Justice Court): 
___________________________________________________________     

[  ] No. 

[  ] I don’t know.   

h.  Other facts:   

 

6. 

Describe past sexual violence involving the respondent (if any): 

a.  When did it happen? (Date.): _______________________________________ 

b.  Where did it happen? (Street, city and state.):  

 

______________________________________________________________ 

c.  Describe the sexual violence (Attach additional sheets if needed.): 

               

 

d.  Did the police come?    [  ] Yes    [  ] No 

e.  If the police came, 

•  Which police department came? _____________________________________ 

1201POF Approved May 13, 2019 
 

Request for Sexual Violence Protective Order 

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•  Was anyone arrested? [  ] Yes    [  ] No 

If yes, who was arrested? ___________________________________________ 

•  Provide police case number if known: ___________________________ 

f.  Did respondent use or threaten to use a gun or other weapon?    

[  ] Yes    [  ] No  (If yes, describe the weapons the respondent owns and how they were 

used against you.): 

g.  Have charges been filed in any court?  

[  ] Yes. 

  Court case number (if known): ____________________________________ 

Court name (for example, Sanpete District Court, Taylorsville Justice Court): 
___________________________________________________________     

[  ] No. 

[  ] I don’t know.   

h.  Other facts:   

 

 

7. 

Respondent and I: 

[  ]  work at the same place. 

[  ]  go to the same school. 

[  ]  attend the same place of worship. 

(Give information the court should consider about potential or necessary interactions with 
respondent at the places listed above.)  

 

 

     

       

1201POF Approved May 13, 2019 
 

Request for Sexual Violence Protective Order 

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8. 

Respondent and one or more of the people listed in paragraph 9 below: 

[  ]  work at the same place. 

[  ]  go to the same school. 

[  ]  attend the same place of worship. 

(List the person and what the court should know about potential or necessary interactions 
between the person and the respondent at the places listed above.)  
 

       

 

 

 

 

 

Request 

I ask the court to: 

•  Grant the temporary orders I have marked below. 

•  Schedule a hearing to be held within 20 days. 

•  After the hearing, make the temporary orders permanent. 

(Choose all that apply.) 

9. 

[  ]  Personal conduct 

Order respondent not to commit, try to commit, or threaten to commit any form of 
sexual violence against me or the people listed below. 

Other people protected by this section (Relatives or people who live with me.): 

Name 

Age 

Relationship to petitioner 

 

 

 

 

 

 

 

 

 

 

10. 

[  ]  No contact 

1201POF Approved May 13, 2019 
 

Order respondent not to contact, phone, text, mail, e-mail, or communicate with 
me and the people listed in paragraph 9 in any way, either directly or indirectly. 

Request for Sexual Violence Protective Order 

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11. 

[  ]  Stay away  

[  ]  Stay at least ____________________________ (distance) from me. 

[  ]  Stay away from:  

[  ]  my home 

[  ]  my work 

[  ]  my school 

[  ]  my place of worship  

[  ]  other: _____________________________________________ 

[  ]  Stay away from the people listed in paragraph 9 at their home, work, 

school, and place of worship and the following other places: 

   

[  ]  Other (specify): 

________________________________________________________ 

12. 

[  ]  No weapons  

Order respondent not to use, possess, have, or buy a firearm or any of these 
weapons: ___________________________________________________ 

 understand it is a serious crime to lie to get a sexual violence protective order. If 
I lie, I can be charged with a class A misdemeanor. 

 declare under criminal penalty under the law of Utah that everything stated in this document is true. 

Signed at ______________________________________________________ (city, and state or country). 

Signature ► 

Printed Name 

 

 

  I

  I

 

 
Date 

1201POF Approved May 13, 2019 
 

Request for Sexual Violence Protective Order 

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