In the District Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

v. 

1. 
 

2. 

3. 

4. 

_____________________________________ 
Petitioner  

Ex Parte Order 

_____________________________________ 
Respondent 

Temporary Sexual Violence 
Protective Order 
(Utah Code 78B-7-501 et seq.) 

_______________________________ 
Case Number 

_______________________________ 
Judge 

_______________________________ 
Commissioner 

The court finds there is reason to believe: 

(Choose one.) 
[  ]  Petitioner is 18 or older, or 

[  ]  Petitioner is under 18 and has been emancipated by marriage or court order. 

It has jurisdiction over the parties in this case. 

Respondent and petitioner are not cohabitants or dating partners. 

Petitioner has been subjected to sexual violence by the respondent. 

The court orders: 

Respondent must obey all orders initialed below. Violation of this order is a criminal 
Class A Misdemeanor, punishable by up to 364 days in jail and a fine. 

5. 

[     ]  Personal Conduct 

Respondent may not commit, try to commit, or threaten to commit sexual 
violence against the petitioner or any person listed below. 

Other people protected by this section (relatives or people who live with petitioner): 

Name  

Age 

Relationship to petitioner 

1202POF Approved May 13, 2019 
 

Temporary Sexual Violence Protective Order 

Page 1 of 5 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. 
 

 

[     ]  No Contact Order 
 

Respondent must not contact, phone, text, mail, e-mail, or communicate in 
any way with the Petitioner and the people listed in paragraph 5 of this 
order either directly or indirectly. 

7. 

[     ]  Stay Away Order 

[    ]  a.  Stay at least ______________________ (distance) from petitioner. 

[    ]  b.  Stay away from petitioner's  

_________________________________________________ 

 [    ] c.  Comply with the following restrictions while at respondent's and 

[  ]  home 

[  ]  work 

[  ]  school 

[  ]  place of worship  

[  ]  other: 

petitioner's  

Work: 

School:  

Place of worship:  

 

 

 

 [    ] d.  Stay away from the people listed in paragraph 5 at their home, 

work, school, and place of worship and the following other places: 

1202POF Approved May 13, 2019 
 

Temporary Sexual Violence Protective Order 

Page 2 of 5 

   

   

   

 [    ] e.   Comply with the following restrictions while at the work, school, 

and place of worship that respondent and the people in paragraph 
5 have in common: 

[   ] 

f.  Other (specify):  

 

8. 

[     ]  No Weapons 

[    ]  The court finds there is clear and convincing evidence that 

respondent’s use or possession of a firearm poses a serious threat 
of harm to the petitioner and the people listed in paragraph 5. 
Respondent cannot possess, have, or buy a firearm.  

[    ]  The court finds that respondent’s use or possession of a weapon 

poses a serious threat of harm to petitioner and the people listed in 
paragraph 5. Respondent cannot possess, have, or buy any of 
these weapons:  

_____________________________________________________. 

Notice to respondent: 

This is a court order. No one except the court can change it. You can tell your side at 
the hearing. If you do not obey this order, you can be arrested, fined, and face other 
charges. 

This order lasts until the hearing on the following date and time: 

Courthouse Address (Dirección del tribunal):  

______________________________________________________________________ 

Date (Fecha): ________________________  Time (Hora): ___________ [  ]  a.m.  [  ]  p.m.   

Room (Sala): ________________________  

1202POF Approved May 13, 2019 
 

Temporary Sexual Violence Protective Order 

Page 3 of 5 

Judge or Commissioner (Juez o Comisionado): __________________________________ 

Attendance  
You must attend. If you do not attend, 
you might be held in contempt of court 
and the relief requested might be 
granted. You have the right to be 
represented by a lawyer. 

Asistencia 
Presentarse es obligatorio. Si usted no 
llegara a presentarse, se lo podría 
encontrar en desacato de las órdenes del 
juez y la reparación solicitada podría ser 
otorgada. Usted tiene el derecho de que lo 
represente un abogado. 

Evidence  
Bring with you any evidence that you 
want the court to consider. 

Pruebas  
Traiga con usted cualquier prueba que 
quiera que el tribunal tome en cuenta. 

Interpretation  
If you do not speak or understand 
English, the court will provide an 
interpreter. Contact court staff 
immediately to ask for an interpreter.  

Interpretación  
Si usted no habla ni entiende el Inglés el 
tribunal le proveeré un intérprete. Contacte 
a un empleado del tribunal inmediatamente 
para pedir un intérprete. 

ADA Accommodation  
If you need an accommodation, including 
an ASL interpreter, contact court staff 
immediately to ask for an 
accommodation. 

Finding help 
The court’s Finding Legal Help web page 
(www.utcourts.gov/howto/legalassist/) 
provides information about the ways you 
can get legal help, including the Self-
Help Center, reduced-fee attorneys, 
limited legal help and free legal clinics. 

Adaptación o Arreglo en Caso de 
Discapacidad  
Si usted requiere una adaptación o arreglo, 
que incluye un intérprete de la lengua de 
signos americana, contacte a un empleado 
del tribunal inmediatamente para pedir una 
adaptación. 

Cómo encontrar ayuda legal 
La página de la internet del tribunal Cómo 
encontrar ayuda legal 
(www.utcourts.gov/howto/legalassist/index-
sp.html/) tiene información sobre algunas 
maneras de encontrar ayuda legal, 
incluyendo el Centro de Ayuda de los 
Tribunales de Utah, abogados que ofrecen 
descuentos u ofrecen ayuda legal limitada, 
y talleres legales gratuitos. 

ommissioner's or Judge’s signature may instead appear at the top of the first page of this document. 

  C

1202POF Approved May 13, 2019 
 

Temporary Sexual Violence Protective Order 

Page 4 of 5 

1202POF Approved May 13, 2019 
 

Temporary Sexual Violence Protective Order 

Page 5 of 5 

Signature ► 

Commissioner 

Signature ► 

Judge 

 

 

 

 

 
Date 

 
Date