Here is the text we could read:
__________________________________
Petitioner’s Name
__________________________________
Address (may be omitted for privacy)
__________________________________
City, State, ZIP
__________________________________
Telephone (may be omitted)
__________________________________
Petitioner,
__________________________________
Respondent
OTICE TO RESPONDENT:
IN THE ____________________ DISTRICT JUVENILE COURT
__________________________________ COUNTY, STATE OF UTAH
EX PARTE
CHILD PROTECTIVE ORDER
Case No. __________________________
Judge _____________________________
YOU CAN BE ARRESTED FOR VIOLATING THIS ORDER EVEN IF ANY PERSON
PROTECTED BY THE ORDER INVITES OR ALLOWS YOU TO VIOLATE THE
ORDER’S PROHIBITIONS. ONLY THE COURT CAN CHANGE THE ORDER. YOU
MAY BE HELD IN CONTEMPT FOR IGNORING OR ALTERING THE TERMS OF THE
ORDER.
he court having found that Petitioner is a person interested in the minor children on whose
behalf the Petition was brought, that Petitioner first made a referral to the Division of Child and
Family Services, and that the Court has jurisdiction over this matter, has reviewed Petitioner’s
Verified Petition for Child Protective Order, from which it appears that the children named
[ ] are being abused or are in imminent danger of being abused.
[ ] have been abused by someone who is not the child's parent, stepparent, guardian, or
custodian.
Approved August 11, 2017 by Board of Juvenile
Court Judges / Revised by Forms Committee
August 9, 2021
Ex Parte Child Protective Order
Page 1 of 7
N
T
vs.
below
Pending further hearing in this matter,
PURSUANT TO UTAH CODE SECTION 78B-7-202, THE PETITIONER IS GRANTED AN
EX PARTE CHILD PROTECTIVE ORDER:
(The Judge shall initial each section that is included in this Order.)
[___] 1. The Respondent is restrained from attempting, committing, or threatening to commit
abuse against the following child/ren and shall not stalk, harass, or threaten to use or
attempt to use physical force that would reasonably be expected to cause physical injury
to the child/ren:
Child’s Name
Relationship to Respondent
___] 2. Except as provided in the parent time section below, the Respondent is prohibited from
harassing, telephoning, contacting, or otherwise communicating with the minor child/ren,
in paragraph 1 directly or indirectly.
___] 3. The Respondent shall be excluded and is ordered to stay away from the residence and
its premises located at: _____________________________________________________
and any known subsequent residence of the minor child/ren, and Respondent is
prohibited from terminating or interfering with the utility services to the residence.
[___] 4. The Respondent is ordered to stay away from:
[ ] Child’s school:
Child’s name
School address (Street, City, State, ZIP)
[ ] Respondent attends the same school as the children. Respondent is not
ordered to stay away from this location, but the following restrictions apply
when the respondent and the children are both there:
Approved August 11, 2017 by Board of Juvenile
Court Judges / Revised by Forms Committee
August 9, 2021
Ex Parte Child Protective Order
Page 2 of 7
[
[
[ ] Child’s place of worship:
Child’s name
Address of place of worship (Street, City, State, ZIP)
[ ] Respondent attends the same place of worship as the children. Respondent is
not ordered to stay away from this location, but the following restrictions
apply when the respondent and the children are both there:
[ ] Child’s work:
Child’s name
Work address (Street, City, State, ZIP)
[ ] Respondent works at the same place as the children. Respondent is not
ordered to stay away from this location, but the following restrictions apply
when the respondent and the children are both there:
[ ] These places, which the child goes to often:
Child’s name
Name of place and address (Street, City, State, ZIP)
___] 5. The Court having found that Respondent’s use or possession of a weapon may pose a
serious threat of harm to minor child/ren, the Respondent is prohibited from purchasing,
using, or possessing a firearm or any of the following weapons:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
[
Approved August 11, 2017 by Board of Juvenile
Court Judges / Revised by Forms Committee
August 9, 2021
Ex Parte Child Protective Order
Page 3 of 7
________________________________________________________________________
[___] 6. The minor child/ren are awarded possession of the following essential personal effects:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
This award is subject to subsequent orders concerning the listed property in future proceedings.
ESPONDENT’S VIOLATION OF “1" THROUGH “6" PROVISIONS OF THIS
ORDER, IS A CLASS A MISDEMEANOR UNDER UTAH CODE SECTION 76-5-108. IF
RESPONDENT’S VIOLATION OF PROVISIONS “1" THROUGH “6" OF THIS
ORDER, IS A SECOND OR SUBSEQUENT DOMESTIC VIOLENCE OFFENSE,
ENHANCED PENALTIES MAY BE IMPOSED UNDER UTAH CODE SECTIONS 77-
36-1.1 AND 77-36-2.4.
HE COURT ORDERS THE FOLLOWING RELIEF IN THE CIVIL PORTION OF
THIS EX PARTE PROTECTIVE ORDER:
The civil portion is effective from the date and time served on the Respondent, until, after
further hearing, the Respondent is served with a protective order, the protective order is
denied, or this matter is dismissed).
IOLATIONS OR FAILURE TO COMPLY WITH THE CIVIL PORTION, LISTED BELOW,
MAY SUBJECT A PERSON TO CONTEMPT PROCEEDINGS.
___] 7. Temporary custody of the minor children shall be as follows:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
[___] 8. The Respondent shall have parent-time as follows:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
R
T
(
V
[
Approved August 11, 2017 by Board of Juvenile
Court Judges / Revised by Forms Committee
August 9, 2021
Ex Parte Child Protective Order
Page 4 of 7
[___] 9. The Respondent is restrained from using drugs and/or alcohol prior to or during parent-
___] 10. The Respondent is restrained from removing the minor child/ren from the state of
time.
Utah.
[___] 11. Support is ordered in accordance with Title 78B, Chapter 12, Utah Child Support Act.
[___] 12. The Division of Child and Family Services shall provide information to the Court as to
the status of Petitioner’s referral.
[___] 13. A guardian ad litem is appointed to represent the best interests of the minor child/ren.
[___] 14. Law enforcement agencies with jurisdiction over the protected locations are hereby
directed and authorized to render any necessary assistance to the above-named petitioner in
retrieving the child/ren named in this Ex-Parte Protective Order and give physical custody
of said child/ren_______________________________________
______________________________________________________ to the petitioner. Such
action includes, but is not limited to, obtaining access to the child/ren through locked doors
and gates and restraining any persons who may attempt to prevent the removal of said
child/ren.
___] 15. Law enforcement agencies with jurisdiction over the protected locations shall
accompany the minor child/ren to ensure that they safely regain possession of the awarded
property.
[___] 16. Law enforcement agencies with jurisdiction over the protected locations shall facilitate
Respondent’s removal of Respondent’s essential personal belongings from the parties’
residence. The law enforcement officer shall contact Petitioner to make these
arrangements. Respondent may not contact the Petitioner or enter the residence to obtain
any item.
[___] 17. Law enforcement agencies with jurisdiction over the protected locations shall have
authority to compel Respondent’s compliance with this Order, including the authority to
forcibly evict and restrain Respondent from the protected areas. Information to assist with
identification of the Respondent is attached to this Order.
[___] 18. The Respondent is ordered to bring proof of current income to the hearing. The proof
should include year-to-date pay stubs or employer statements, and complete tax returns for
the most recent year.
[___] 19. Other: ________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Approved August 11, 2017 by Board of Juvenile
Court Judges / Revised by Forms Committee
August 9, 2021
Ex Parte Child Protective Order
Page 5 of 7
[
[
________________________________________________________________________
___] 20. (IN FOSTER CARE CASES ONLY) Remaining in the home would be contrary to the
welfare of the child and it is in the best interest of the child to be removed from the home
and placed in foster care. The Court makes this determination based on the evidence
presented in the petition for an ex parte protective order, specifically:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
21. Unless otherwise modified by the court, this Order is effective from the date and time
served on Respondent, until, after further hearing in this matter, the Respondent is served
with a Child Protective Order or a Child Protective Order is denied.
22. The Respondent is ordered to appear at a hearing which will be held on:
Y THE COURT:
B
ATED: _________________________ TIME: _____________
xpiration date: ________________
Date:
Time:
Room:
Address:
______________________________________
JUVENILE COURT JUDGE
x Parte Child Protective Order–Notice to Petitioner
etitioner may provide a copy of this order to the children’s school principal. (Utah Code 78B-7-
105(2)(b)(ii))
this order.
etitioner may enforce a court order if respondent violates or fails to comply with provision(s) of
f the respondent fails to return custody of a minor child to the petitioner as ordered, the
petitioner can get a writ of assistance from the court (Utah Code 78B-7-105(2)(b)(iii))
ach party is entitled to have an attorney present at the hearing(s).
Approved August 11, 2017 by Board of Juvenile
Court Judges / Revised by Forms Committee
August 9, 2021
Ex Parte Child Protective Order
Page 6 of 7
[
E
D
E
P
P
I
E
OU CANNOT WAIVE, ALTER, IGNORE, OR DISMISS THIS ORDER WITHOUT
FURTHER COURT ACTION. YOU MAY BE HELD IN CONTEMPT FOR IGNORING OR
ALTERING THE TERMS OF THIS ORDER.
Y
Approved August 11, 2017 by Board of Juvenile
Court Judges / Revised by Forms Committee
August 9, 2021
Ex Parte Child Protective Order
Page 7 of 7
