Here is the text we could read:
IN THE ____________________ DISTRICT JUVENILE COURT
__________________________________ COUNTY, STATE OF UTAH
CHILD PROTECTIVE ORDER
vs.
ase No. __________________________
__________________________________
Judge _____________________________
C
__________________________________
Petitioner,
Respondent
OTICE TO RESPONDENT:
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.
his matter came for hearing on _____________________. The following parties were in
attendance:
[___] Petitioner
[___] Respondent
[___] Guardian ad Litem
[___] Petitioner’s attorney ___________________________
[___] Respondent’s attorney __________________________
he Court has reviewed Petitioner’s Verified Petition for Child Protective Order and:
[___] has received argument and evidence
[___] has accepted the stipulation of the parties
[___] has entered the default of the Respondent for failure to appear
Approved Augut11, 2017 by Board of Juvenile
Court Judges / Revised by Forms Committee July
1, 2020
Child Protective Order
Page 1 of 9
N
T
T
__________________________________
Petitioner’s Name
__________________________________
Address (may be omitted for privacy)
__________________________________
City, State, ZIP
__________________________________
Telephone (may be omitted)
the Court finds the minor children listed below are being abused or are in
imminent danger of being abused.
the Court finds the minor children listed below have been abused by someone
who is not the child's parent, stepparent, guardian, or custodian.
[___]
[___]
therefore THE PETITIONER IS GRANTED A CHILD PROTECTIVE ORDER
PURSUANT TO UTAH CODE SECTION 78B-7-202:
(The Judge or Commissioner 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 children, 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 paragraph (b), 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 Augut11, 2017 by Board of Juvenile
Court Judges / Revised by Forms Committee July
1, 2020
Child Protective Order
Page 2 of 9
[
[ ] 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 finds 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 Augut11, 2017 by Board of Juvenile
Court Judges / Revised by Forms Committee July
1, 2020
Child Protective Order
Page 3 of 9
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
[___] 6. The minor child/ren are awarded possession of the following essential personal effects:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
his award is subject to subsequent orders concerning the listed property in future proceedings.
7. 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 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.
8. 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.
. 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 items.
9
ESPONDENT’S VIOLATION OF PROVISIONS “1" THROUGH “9" OF THIS
ORDER, IS A CLASS A MISDEMEANOR UNDER UTAH CODE SECTION 76-5-108.
F RESPONDENT’S VIOLATION OF PROVISIONS “1" THROUGH “9" 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.
Approved Augut11, 2017 by Board of Juvenile
Court Judges / Revised by Forms Committee July
1, 2020
Child Protective Order
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T
R
I
IOLATION OF PROVISIONS “a” THROUGH “i” BELOW MAY SUBJECT
RESPONDENT TO CONTEMPT PROCEEDINGS.
[___] a. The Petitioner is granted custody of the following minor child/ren:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
V
___] b. The Respondent shall have parent-time as follows:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
The Respondent is restrained from using drugs and/or alcohol prior to or during
parent-time.
___] c. The Respondent is restrained from removing the minor child/ren from the state of
Utah.
___] d. The Respondent is ordered to pay child support in the amount of $_____________
pursuant to the Utah Uniform Child Support Guidelines.
___] e. The Respondent is ordered to participate in mandatory income withholding
pursuant to Utah Code Annotated § 62A-11, Parts 4 and 5.
___] f. The Respondent is ordered to pay one-half of the minor child/ren’s day care
expenses.
___] g. The Respondent is ordered to pay one-half of the minor child/ren’s medical
expenses including premiums, deductibles and co-payments.
___] h. The Respondent is ordered to pay the minor child/ren’s medical expenses, suffered
as a result of the abuse in the amount of $_______________.
[___] i. Other:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
[
[
[
[
[
[
[
Approved Augut11, 2017 by Board of Juvenile
Court Judges / Revised by Forms Committee July
1, 2020
Child Protective Order
Page 5 of 9
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
[___] 10. The Division of Child and Family Services shall provide information to the Court as
to the status of Petitioner’s referral.
[___] 11. A guardian ad litem is appointed to represent the best interests of the minor child/ren.
___] 12. 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.
___] 13. Under federal law, the Respondent may be prohibited from purchasing, owning,
transporting, using or possessing a firearm and ammunition. There is an exemption for
police and military personnel while on actual duty and those persons need to contact their
immediate supervisors for further instructions regarding compliance with federal law.
14. Respondent was afforded both notice and opportunity to be heard in the hearing that
gave rise to this order. Pursuant to the Violence Against Women Act of 1994, P.L. 103-
322, 108 Stat. 1976, 18 U.S.C.A. 2265, this order is valid in all the United States, the
District of Columbia, tribal lands, and United States Territories. This order complies with
the Uniform Interstate Enforcement of Domestic Violence Protection Orders Act.
[
[
15. Expiration of Order
Child’s name
Date order expires
Relationship to
respondent
Reason
[___] This order expires 150 days because the respondent is the
parent, stepparent, guardian or custodian of the child.
[___] This order expires in less than 150 days because:
_______________________________________________
_______________________________________________
_______________________________________________
[___] This order expires in more than 150 days for the following
Approved Augut11, 2017 by Board of Juvenile
Court Judges / Revised by Forms Committee July
1, 2020
Child Protective Order
Page 6 of 9
Child’s name
Date order expires
Relationship to
respondent
Reason
good cause:
_______________________________________________
_______________________________________________
_______________________________________________
[___] This order expires when the child turns 18 because the
respondent is not a parent, stepparent, guardian or
custodian of the child.
[___] This order expires 150 days because the respondent is the
parent, stepparent, guardian or custodian of the child.
[___] This order expires in less than 150 days because:
_______________________________________________
_______________________________________________
_______________________________________________
[___] This order expires in more than 150 days for the following
good cause:
_______________________________________________
_______________________________________________
_______________________________________________
[___] This order expires when the child turns 18 because the
respondent is not a parent, stepparent, guardian or
custodian of the child.
Child’s name
Date order expires
Relationship to
respondent
Reason
[___] This order expires 150 days because the respondent is the
parent, stepparent, guardian or custodian of the child.
[___] This order expires in less than 150 days because:
_______________________________________________
_______________________________________________
_______________________________________________
Approved Augut11, 2017 by Board of Juvenile
Court Judges / Revised by Forms Committee July
1, 2020
Child Protective Order
Page 7 of 9
Child’s name
Date order expires
Relationship to
respondent
Reason
[___] This order expires in more than 150 days for the following
good cause:
_______________________________________________
_______________________________________________
_______________________________________________
[___] This order expires when the child turns 18 because the
respondent is not a parent, stepparent, guardian or
custodian of the child.
[___] This order expires 150 days because the respondent is the
parent, stepparent, guardian or custodian of the child.
[___] This order expires in less than 150 days because:
_______________________________________________
_______________________________________________
_______________________________________________
[___] This order expires in more than 150 days for the following
good cause:
_______________________________________________
_______________________________________________
_______________________________________________
[___] This order expires when the child turns 18 because the
respondent is not a parent, stepparent, guardian or
custodian of the child.
ATED: _________________________.
BY THE COURT:
______________________________________
JUVENILE COURT JUDGE
Approved Augut11, 2017 by Board of Juvenile
Court Judges / Revised by Forms Committee July
1, 2020
Notice to Petitioner
Child Protective Order
Page 8 of 9
D
Petitioner may provide a copy of this order to the children’s school principal. (Utah Code 78B-7-
105(2)(b)(ii))
etitioner may enforce a court order if respondent violates or fails to comply with provision(s) of
he address provided by the petitioner will not be made available to the respondent.
f at any time, you receive services through the Office of Recovery Services, and you want to
keep your location information confidential, you must provide a copy of your current protective
order to ORS.
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.
this order.
P
T
I
Y
Approved Augut11, 2017 by Board of Juvenile
Court Judges / Revised by Forms Committee July
1, 2020
Child Protective Order
Page 9 of 9
