Request for Civil  
Stalking Injunction 
 

Case Number:  _______  District:  __________ 
County:  _____________ State:  Utah 
Judge:   _______________________________ 

   Petitioner (person needing protection): 

________________ 
First Name 

____________ 
Middle 

____________  
Last 

The Respondent and I have the following minor 

Children: 

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

Name 

___________________________________ 
Street 

___________________________________ 
City --- State --- Zip 

___________________________________ 
Phone # 

__________________________ 
__________________________ 

__________________________ 
__________________________ 

__________________________ 
__________________________ 

Age 

____ 
____ 

____ 
____ 

____ 
____ 

etitioner’s attorney (if any):________________________________________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  --- City --- 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 your 
property using any action, method, device, or means; or 

b. the Respondent engaged in or caused someone else to engage in any of the following acts:  
  i.   approached or confronted you; 
  ii.  appeared at your workplace or contacted your employer or co-workers; 
  iii. appeared at your home or contacted your neighbors or entered property owned, leased, or occupied                   
……by you; 

Approved by Board of District Court Judges, June 2013 /  
Revised by Forms Committee April 11, 2022 

Request for Civil Stalking Injunction 

Page 1 of 5 

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   iv. sent material to you by any means for the purpose of obtaining or disseminating information about 

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 your 

place of employment with intent that the object be delivered to you; or 

    vi. used a computer, the Internet, text messaging, or any other electronic means. 
 

For a complete definition of stalking, see Utah Code 76-5-106.5.  

ote!  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. If you don’t know, write “unknown.” 
Respondent’s Employer (Name and address): _________________________________________________ 

______________________________________________________________________________________ 

Best place and time to find the Respondent: (Place): __________________ (Time):____________________ 

Other addresses (hangouts):  ______________________________________________________________ 

______________________________________________________________________________________ 

Describe the Respondent’s vehicle: Make:____ 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   [__]  Don’t know 

Is the Respondent a law enforcement officer, government investigator,  
or licensed private investigator?  

 

[__]  Yes  [__]  No   [__]  Don’t know 

4   Describe the stalking below:  

 a.  When and where did the stalking events happen? (Attach additional pages if necessary.) 

 

 

 

            

  N

1st stalking event: 

2nd stalking event: 

When: _________________________________________________________________________ 

Where: ________________________________________________________________________ 

When: _________________________________________________________________________ 

Where: ________________________________________________________________________ 

            Other stalking events: _______________________________________________________________ 

When: _________________________________________________________________________ 

Where: ________________________________________________________________________ 

b.  Who did you report the stalking to (if anyone)? ____________________________________________ 

Approved by Board of District Court Judges, June 2013 /  
Revised by Forms Committee April 11, 2022 

 

Request for Civil Stalking Injunction 

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c.  List names of all people who witnessed the stalking: _______________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________ 

_________________________________________________________________________________

_________________________________________________________________________________  

d.  List any evidence you have of the stalking, like transcripts, audiotapes, police reports, photos, sworn 

statements 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 emotionally 

distressed, 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.)  

Approved by Board of District Court Judges, June 2013 /  
Revised by Forms Committee April 11, 2022 

 

Request for Civil Stalking Injunction 

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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): 

Type of Case 

County and State 

Court Case #  
(NOT the police report #) 
 

Person involved 

[__] You  [__] Respondent 

Did the judge make 
 an order? 
[__] 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:  
Relationship to 
Petitioner 

Name 

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 ___________________________________________ 
______________________________________________________________________________ 

Approved by Board of District Court Judges, June 2013 /  
Revised by Forms Committee April 11, 2022 

Request for Civil Stalking Injunction 

Page 4 of 5 

 

 

 

______________________________________________________________________________ 

 

    Name someone who can communicate parent-time information to the Respondent: ____________ 
______________________________________________________________________________ 

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, and 
I live in this county or the Respondent lives in this county, or I am temporarily living 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). 

 
Date 

I swear that: 

Signature ► 

Printed Name 

If the Petitioner is a minor, then a parent or guardian must sign below. 

I am Petitioner’s parent or guardian and I have read this Request for Civil Stalking Injunction, 

• 
•  Petitioner is a victim of stalking and I believe the Respondent is the stalker, and 
•  The Petitioner lives in this county or the Respondent lives in this county, or is temporarily living 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). 

Parent or 
Guardian's 
Signature    ► 

Parent or Guardian's Printed Name 

 
Date 

 

 

Approved by Board of District Court Judges, June 2013 /  
Revised by Forms Committee April 11, 2022 

Request for Civil Stalking Injunction 

Page 5 of 5