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Protective Order
(Utah Code 78B-7-603)
Petitioner (protected person):
Case Number: _____________________ District:_____
County: ___________________________ State: Utah
Judge: _______________________________________
Commissioner: ________________________________
Page 1 of 7
Name
irst Name
Middle
Last
ddress and phone # (to keep private, leave blank):
Other people protected by this order
__________________________________
Street
___________________________________
City --- State --- Zip
___________________________________
Phone #
_____________________
_____________________
_____________________
_____________________
Age
____
____
____
____
Relationship to
Petitioner
_____________
_____________
_____________
_____________
Petitioner’s date of birth: ___________________
_____________________
____ _____________
Petitioner’s attorney (if any):_______________________________________ Phone #_______________
Sex
Describe Respondent
Date of Birth
Race
Ht.
Wt.
_______ _______ _________ ______ ______
_________
Last
_________
Middle
espondent
person Petitioner is protected from):
___________
(
_
First Name
ther Names Used _______________________
Eyes
Hair
Social Security #
____________________________________
(only the last 4 numbers)
______
______
____________
elationship to Petitioner: ________________________
Address (street): _______________________________
Distinguishing features (like scars, tattoos, limp, etc.)
_______________________________________________
_____________________________________________
City --- State --- Zip
_______________________________________________
Driver’s license issued by (State):______ Expires: ________
Phone Number: ________________________
Warning! [__] Weapon involved (Box to be initialed by Court, if applicable)
here was a hearing on (date): ______________________. The Respondent was given notice and an
opportunity to be heard in the hearing that gave rise to this order. The following people were present at
the hearing:
[__] Petitioner
[__] Respondent [__] Respondent’s attorney (name):
[__] Other (name)
[__] Petitioner’s attorney (name):
he Court reviewed the Request for Protective Order and [__] received argument and evidence, [__]
accepted the stipulation of the parties, [__] entered the default of the Respondent for failure to appear,
Protective Order
Approved Board of District Court Judges May 21, 2008
Revised April 11, 2022
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finds that domestic violence or abuse has occurred or there is substantial likelihood of abuse or domestic
violence by the Respondent, [__] finds that a minor child witnessed the abuse or domestic violence, and
makes the orders initialed below.
[ ] The petitioner is an intimate partner of the respondent.
The term “intimate partner” means, with respect to a person, the spouse of the person, a former spouse of the person, an
individual who is a parent of a child of the person, and an individual who cohabitates or has cohabited with the person. 18
USC Sec. 921 (a)(32).
[ ] The party to be protected is the child of an intimate partner to the respondent.
] Mutual Protective Order (Utah Code 78B-7-108)
The court is entering a mutual protective order because:
• each party filed an independent petition against the other for a protective order and both petitions
are served
• each party has made a showing at a due process protective order hearing because of abuse or
domestic violence committed by the other party; and
• each party demonstrates the abuse or domestic violence did not occur in self-defense.
arnings:
• This is a court order. No one except the court can change it. If you do not obey this order, you can be
arrested, fined, and face other charges.
• This order is valid in all U.S. states and territories, the District of Columbia, and tribal lands. If you go
to another U.S. state, territory or tribal land to violate this order, a federal judge can send you to
prison.
• No guns or firearms! (See paragraph 5.)
Violence Against Women Act of 1994, 18 U.S.C. Sec. 2265, 2262, 18 U.S.C. 922(g)(8)
espondent must obey all provisions initialed below.
riminal orders (you can be arrested for violating these)
If you (respondent) violate orders 1-6 it is a criminal Class A Misdemeanor, punishable by up to 364 days in
jail and a fine. A second or subsequent violation can result in more severe penalties.
1 [___]
2 [___]
3 [___]
Personal Conduct Order -- Do not commit, try to commit or threaten to commit any form of
violence against the Petitioner or any person listed on the first page of this form. This includes
stalking, harassing, threatening, physically hurting, or causing any other form of abuse.
No Contact Order -- Do not contact, phone, mail, e-mail, or communicate in any way with
the Petitioner and the people listed on the first page of this order either directly or indirectly
except as allowed by the parent-time provisions of this order.
Contact during Mediation -- You are allowed to have contact with the Petitioner only
during mediation sessions for your divorce or custody case that are scheduled with a Court
Qualified Mediator.
Protective Order
Approved Board of District Court Judges May 21, 2008
Revised April 11, 2022
Page 2 of 7
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4 [___]
Stay Away Order
[ ] a. Stay at least _______________________________ (distance) from the Petitioner.
[ ] b. Stay away from Petitioner's
Home: _________________________________________________________ (address)
Work : _________________________________________________________ (address)
School: ________________________________________________________ (address)
Place of worship: _________________________________________________ (address)
[ ] c.
Must comply with the following restrictions while at Respondent's and Petitioner's
Work : _________________________________________________________ (address)
______________________________________________________________________________
______________________________________________________________________________
School: _________________________________________________________ (address)
______________________________________________________________________________
______________________________________________________________________________
Place of worship: _________________________________________________ (address)
______________________________________________________________________________
______________________________________________________________________________
[ ] d. Stay away from the people listed on the first page of this form at their:
Home: _________________________________________________________ (address)
Work : _________________________________________________________ (address)
The respondent [ ] does [ ] does not work at the same place as the people listed on
the first page of this form.
School: _________________________________________________________ (address)
The respondent [ ] does [ ] does not go to the same school as the people listed on
the first page of this form.
Place of worship: _________________________________________________ (address)
The respondent [ ] does [ ] does not attend the same place of worship as the people
listed on the first page of this form.
[ ] e. Must comply with the following restrictions while at Respondent's and the people
listed on the first page of this form's:
Work : _________________________________________________________ (address)
______________________________________________________________________________
______________________________________________________________________________
School: _________________________________________________________ (address)
______________________________________________________________________________
Protective Order
Approved Board of District Court Judges May 21, 2008
Revised April 11, 2022
Page 3 of 7
______________________________________________________________________________
Place of worship: _________________________________________________ (address)
______________________________________________________________________________
______________________________________________________________________________
[__] f. Other (specify): ____________________________________________________________
5 [___]
No Guns or Other Weapons -- The Court finds that your use or possession of a weapon
poses a serious threat of harm to the Petitioner. You cannot possess, have, or buy a gun or
firearm or any of these weapons: _____________________________________________
arning! If a final protective order is issued against you after the hearing, you will then
become subject to the federal law making it a crime to possess, transport, ship or receive any
firearm or ammunition, including a hunting weapon.
Property Orders -- Until further court order, Only the Petitioner can use, control and
possess the following property and things, but cannot dispose of this property without court
approval:
[__] a. Home at (address):
_______________________________________________________
[__] b. Car, truck or other property (describe):
_______________________________________________________
ivil orders (you can be in held contempt of court for violating these)
If you (respondent) violate orders 7-14, you will be in contempt of court and may be punished with jail time
and fines.
7 [___]
Property Orders
[ ] You cannot interfere with or change Petitioner's phone, utility or other services.
[ ] You must maintain Petitioner's existing wireless phone contracts or accounts.
No Harming Pets Do not physically injure or threaten to injure a pet that is:
[ ] a. Owned or kept by the Petitioner. Do not take possession of the Petitioner’s pet.
[ ] b. Owned or kept by you.
9 [___]
Transfer Wireless Phone Number(s)
You must transfer the Petitioner's current wireless phone number(s) to a new account of their
choice.
The court will issue a separate order to the wireless service provider to transfer Petitioner's
wireless phone number(s) to a new account.
10 [___]
Child Custody & Parent-time Orders –
[ ] The Petitioner (the person asking for protection)
Protective Order
Approved Board of District Court Judges May 21, 2008
Revised April 11, 2022
Page 4 of 7
W
6 [___]
C
8 [___]
[ ]
_______________________________________________________________ (name)
will have temporary custody of the minor children of the parties listed below. The person with
custody may give a copy of this order to the principal or director of the child’s school or
daycare. If you do not obey the custody and parent-time orders listed here, the person with
custody may ask for the court’s help by filing a motion to enforce the order:
__________________________________________________________________________
__________________________________________________________________________
You will have parent-time as follows:
___________________________________________________________________________
___________________________________________________________________________
If there is a “No Contact” order, you can communicate with the Petitioner or person with
custody only about parent-time matters through:
_____________________________________________________________________
11 [___]
No Alcohol or Illegal Drugs -- Do not use alcohol or illegal drugs before or during
visitation.
12 [___]
No Travel with Children -- Do not take the children listed above out of Utah.
13 [___]
Child Support, Spousal Support and other Expenses -- The Respondent will:
[__] a. Pay $ ______ / month in child support.
[__] b. Have child support withheld from the Respondent’s earnings. (Utah Code 62A-11,
Parts 4 and 5)
[__] c. Pay $ ______ / month in spousal support.
[__] d. Pay 50% of the minor children’s childcare expenses.
[__] e. Pay 50% of the minor children’s medical expenses, including premiums,
deductibles and
co-payments.
abuse and
[__] f. Pay $ _________ for the minor children’s medical expenses related to the
$ __________ for the Petitioner’s medical expenses related to the abuse.
14 [___]
Other Assistance Needed (List below any other orders needed to protect you and other
protected people listed on page 1 of this
form):____________________________________________
___________________________________________________________________________
___________________________________________________________________________
Law Enforcement to Assist A law enforcement officer
from:___________________________
will enforce the orders checked below:
rders to Agencies
15 [___]
O
Protective Order
Approved Board of District Court Judges May 21, 2008
Revised April 11, 2022
Page 5 of 7
[__] a. Help the Petitioner gain and keep control over home, car or other personal
[__] b. Help the Petitioner obtain custody of the children.
[__] c. Help the [__] Respondent or [__] Petitioner remove essential personal belongings
belongings.
from the home.
“Essential personal belongings” means daily use items, such as clothing, medications, jewelry,
toiletries, financial or personal records solely in one person’s name, or items needed to work at
a job or go to school.
Warning to the Respondent: Do not go into the home or other protected places without
the officer.. Law enforcement can evict you or keep you away from protected places, if
needed.
16 [___]
Investigate Possible Child Abuse -- This matter will be referred to the Division of Child
and Family Services for review and possible investigation of child abuse.
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. 1796, 18 U.S.C.
Sec. 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. (Utah Code 78B-7-105.5(4)).
Paragraphs 1-6 of this protective order expires in
three years, on
________________________ (date)
(Utah Code 78B-7-606)
Paragraphs 7-14 of this protective order expire in
150 days, on
________________________ (date)
(Utah Code 78B-7-606)
The court could extend the expiration date for paragraphs 7-
13.
Notice to petitioner
The court may amend or dismiss a protective order after one year if it finds that the basis for the
issuance of the protective order no longer exists and the petitioner has repeatedly acted in
contravention of the protective order provisions to intentionally or knowingly induce the respondent
to violate the protective order, demonstrating to the court that the petitioner no longer has a
reasonable fear of the respondent. (Utah Code 78B-7-105(6)(c)).
Protective Order
Approved Board of District Court Judges May 21, 2008
Revised April 11, 2022
Page 6 of 7
The respondent can ask to dismiss the criminal provisions of this protective order within two
years of the date the order is issued, but only if the petitioner agrees to the dismissal. (Utah Code 78B-
7-603(10)).
f you receive services from the Office of Recovery Services (ORS) and want to keep your address
confidential, you must give ORS a copy of your current Protective Order.
Judge or commissioner’s signature may instead appear at the top of the first page of this document.
— The Court fills out below —
Signature ►
Commissioner
Signature ►
Judge
— The Respondent fills out below —
By signing here, the Respondent approves the form, and accepts service of this Protective Order
and waives the right to be personally served.
Respondent’s Address
Street
City
State
Zip
Respondent’s Signature __________________________________________________________
Date
Date
I
Protective Order
Approved Board of District Court Judges May 21, 2008
Revised April 11, 2022
Page 7 of 7
