Here is the text we could read:
Law Enforcement: Do not provide this document to respondent, it contains confidential
information.
Instructions to the court: Do not place in court file. Provide to law enforcement only.
Service Assistance Form
Document to
be Served
Verified Petition for ExParte
Child Protective Order
[__] Parent/Guardian (if
different than Respondent)
Information About the Party
to be Served
[__] Respondent
Name
Alias/Nickname
Home
address
Home phone
Best times to reach
Work
name &
address
Work phone
Best times to reach
Cell phone
SSN
Race
Weight
Hair Color
Special characteristics (tattoos, scars, etc.)
DOB
Sex
Height
Eye Color
river’s license
number
Vehicle license
number
Make
Year
If this person is on probation or parole, list the
name of the agency, officer, and telephone
number.
Model
Color
as this person used weapons in a
threatening manner or been violent in the
past? [__] Yes [__] No
D
H
Case
Number
Court
Address
nformation About You
[__] Petitioner
Name
Alias/Nickname
Home
address
Home phone
Best times to reach
Work
name &
address
Work phone
Best times to reach
Cell phone
DOB
NSTRUCTIONS:
I
I
1
2
. Complete as many of the questions as
possible. If you do not know the answer, you
may leave the question blank.
. If the Parent or Guardian of the child(ren) is
different than the Respondent, complete one
copy of this form with information about the
Respondent and a second copy with
information about the Parent or Guardian.
Approved Board of Juvenile Court Judges
June 12, 2009 / Revised by Forms
Committee July 1, 2020
Service Assistance Form
Page 1 of 1
(may be omitted for security
reasons, if omitted please
explain)
__________________________________
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,
VERIFIED PETITION FOR
EX PARTE CHILD
PROTECTIVE ORDER
_________________________________
Respondent
udge _____________________________
ase No. __________________________
ETITIONER 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 78B-
7-202)
[___] Petitioner made a referral of abuse to the Division of Child and Family Service
based upon the incidents alleged in the petition.
he Petitioner alleges:
1. Petitioner is seeking a protective order on behalf of the following child/ren:
NAME
BIRTH DATE ADDRESS
_
_
P
T
vs.
C
J
Approved October 9, 2009 by Board of Juvenile
Court Judges / Revised by Forms Committee
August 9, 2021
Verified Petition for Ex Parte Child Protective Order
Page 2 of 8
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
Lived With
ADDRESS
(include name and dates)
(city/county/state only)
3a. 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 __________________ (date), at_____________________________ (city),
Utah, the following events occurred that Petitioner believes the children
[___] 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.
Abuse is:
• physical abuse
• sexual abuse
• a sexual offense under Utah Code 76-5b-201 or 204
• human trafficking of a child under Utah Code 76-5-308.5
Approved October 9, 2009 by Board of Juvenile
Court Judges / Revised by Forms Committee
August 9, 2021
Verified Petition for Ex Parte Child Protective Order
Page 3 of 8
[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 physical or sexual abuse. Attach more sheets if necessary but only
write on one side.]
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
___] 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.
___] 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):
arty Who Filed the
Filing Date or
Judgment Date
Court or County where Case
Filed
Case Number
and Case Type
Verified Petition for Ex Parte Child Protective Order
Page 4 of 8
Approved October 9, 2009 by Board of Juvenile
Court Judges / Revised by Forms Committee
August 9, 2021
[
[
Case
P
6. Check one:
___] Petitioner has not filed for a protective order in any other court of the State.
___] 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):
espondent; relationship to
Date of filing
or judgment
Court or County
where case filed
Has a judge signed
an order?
HEREFORE: I respectfully request that this Court:
rder 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
within 21 days, issue a Child Protective Order containing the following relief (Check boxes of
relief that you are requesting):
W
O
Petitioner
R
7. Check one:
___] Restrain the Respondent from attempting, threatening or committing abuse against
the minor children 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.
[___] Prohibit the Respondent from directly or indirectly contacting, harassing,
telephoning, e-mailing, or otherwise communicating with the minor children.
___] 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.
___] Order the respondent to stay away from:
(If the children and respondent go to the same school, place of worship or place of employment, the
court cannot order respondent to stay away from those places. However, you can ask for restrictions
at those locations, such as distance to stay away, areas, or periods of time not to be present.)
[ ] Child’s school:
Child’s name
School address (Street, City, State, ZIP)
Approved October 9, 2009 by Board of Juvenile
Court Judges / Revised by Forms Committee
August 9, 2021
Verified Petition for Ex Parte Child Protective Order
Page 5 of 8
[
[
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[ ] Respondent does not attend the same school as the children.
[ ] Respondent attends the same school as the children and I ask for the
following restrictions at that location:
[ ] Child’s place of worship:
Child’s name
Address of place of worship (Street, City, State, ZIP)
[ ] Respondent does not attend the same place of worship as the children.
[ ] Respondent attends the same place of worship as the children and I ask
for the following restrictions at that location:
[ ] Child’s work:
Child’s name
Work address (Street, City, State, ZIP)
[ ] Respondent does not work at the same place as the children.
[ ] Respondent works at the same place as the children and I ask for the
following restrictions at that location:
[ ] These places, which the child goes to often:
Child’s name
Name of place and address (Street, City, State, ZIP)
Approved October 9, 2009 by Board of Juvenile
Court Judges / Revised by Forms Committee
August 9, 2021
Verified Petition for Ex Parte Child Protective Order
Page 6 of 8
___] Prohibit the Respondent from purchasing, using, or possessing a firearm or other
weapon as designated by the court, including:
________________________________________________________________________
________________________________________________________________________
[___] Award possession of the following personal property:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
___] 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.
___] 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.
___] Grant appropriate custody of the minor children.
___] Order the following parent-time arrangement (if requesting parent-time arranged
through or supervised by another person, identify that person):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
___]Restrain Respondent from using drugs and/or alcohol prior to or during parent-time.
___]Restrain Respondent from removing the minor children from the state.
___]Order Respondent to pay child support in the amount of $______________ pursuant
to the Utah Uniform Child Support Guidelines.
___]Order Respondent to participate in mandatory income withholding pursuant to Utah
Code Annotated § 62A-11, Parts 4 and 5.
___] Order Respondent to pay one-half of the minor child/ren’s day care expenses.
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Approved October 9, 2009 by Board of Juvenile
Court Judges / Revised by Forms Committee
August 9, 2021
Verified Petition for Ex Parte Child Protective Order
Page 7 of 8
[___] Order Respondent to pay one-half of the minor child/ren’s medical expenses
including premiums, deductibles and co-payments.
___] Order Respondent to pay the minor children’s medical expenses suffered as a result
of abuse in the amount of $_____________________.
[___] Order any other relief that the court considers necessary for the safety and welfare
of the children, including the following:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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
Date
Approved October 9, 2009 by Board of Juvenile
Court Judges / Revised by Forms Committee
August 9, 2021
Verified Petition for Ex Parte Child Protective Order
Page 8 of 8
