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Temporary Protective Order
Ex Parte Order
(Utah Code 78B-7-603)
Petitioner (protected person):
Case Number: _____________________ District:_____
County: ___________________________ State: Utah
Judge: _______________________________________
Commissioner: ________________________________
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: ________
Warning! [__] Weapon involved (Box to be initialed by Court, if applicable)
Findings: The Court finds there is reason to believe: it has jurisdiction over the parties and this case, the
Respondent and Petitioner are cohabitants, the Respondent will be served notice of his/her opportunity to be
heard at the scheduled hearing, and the Respondent has abused or committed domestic violence against
Petitioner, or that there is a substantial likelihood that Respondent immediately threatens Petitioner’s physical
safety.
[ ] 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).
Temporary Protective Order
Approved Board of District Court Judges May 21, 2008
Revised by Forms Committee April 11, 2022
Page 1 of 7
F
A
_
R
O
R
[ ] The party to be protected is the child of an intimate partner of the respondent.
The Court orders the Respondent to obey all orders initialed on this form and to not abuse, or threaten to
abuse, anyone protected by this order.
[___] You must not have any contact with the Petitioner.
(The court fills out this section)
This order lasts until the hearing on:
_____________________________________
Month – Day – Year
Or later, if the Court extends time for service.
arnings to the Respondent:
• This is a court order. No one except the court can change it. You can tell your side when you go to
court. 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 item 5.)
o: (Respondent’s name):_______________________________________________________
Go to the court hearing on the date listed below. If you do not go to the hearing, the judge can
make orders without hearing your side.
Date: ____________
Time: _______ [__] a.m. [__] p.m.
Judicial Officer: __________________
Address: ______________________________________________________
Room: ____________
espondent must obey all orders marked 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.
[___]
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.
Temporary Protective Order
Approved Board of District Court Judges May 21, 2008
Revised by Forms Committee April 11, 2022
Page 2 of 7
W
T
R
C
1
[ ] 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)
______________________________________________________________________________
______________________________________________________________________________
chool: _________________________________________________________ (address)
______________________________________________________________________________
______________________________________________________________________________
lace 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)
S
P
2 [___]
3 [___]
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 for Mediation You are allowed to have contact with the Petitioner only during court
mediation sessions for your divorce or custody case that are scheduled with a Court Qualified
Mediator.
4 [___]
Stay Away Order
Temporary Protective Order
Approved Board of District Court Judges May 21, 2008
Revised by Forms Committee April 11, 2022
Page 3 of 7
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)
______________________________________________________________________________
______________________________________________________________________________
chool: _________________________________________________________ (address)
______________________________________________________________________________
______________________________________________________________________________
lace of worship: _________________________________________________ (address)
______________________________________________________________________________
______________________________________________________________________________
[__]
f. Other (specify): _____________________________________________________________________
___________________________________________________________________
___________________________________________________________________
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: _______________________________________________
Warning! 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 the hearing, 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):
___________________________________________________________________
S
P
5 [___]
6 [___]
Approved Board of District Court Judges May 21, 2008
Revised by Forms Committee April 11, 2022
Page 4 of 7
ivil orders (you can be held in contempt of court for violating these)
If you (respondent) violate orders 7-15, you will be in contempt of court and may be punished with jail time
and fines.
7 [___]
Property Orders
Temporary Protective Order
C
[ ] You cannot interfere with or change Petitioner's phone, utility or other services.
[ ] You must maintain Petitioner's existing wireless phone contracts or accounts.
8 [___]
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 [___]
Proof of Income You and Petitioner must bring the following proof of income to the hearing:
pay stubs or employer statements for this year, and complete tax returns for the most recent
year.
11 [___]
Child Custody & Parent-time Orders
[ ] The Petitioner (the person asking for protection)
[ ]
_______________________________________________________________ (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 (such as an order to show cause for
contempt):____________________________________________
__________________________________________________________________________
[__] You will have parent-time as follows: _________________________________________
If there is a “No Contact” order, you can communicate with the Petitioner or the person with
custody only about parent-time matters through:
_________________________________________________________
12 [___]
No Parent Time No parent time is allowed until the scheduled hearing.
13 [___]
No Alcohol or Illegal Drugs Do not use alcohol or illegal drugs before or during visitation.
14 [___]
No Travel with Children Do not take the children listed above out of the state of Utah.
15 [___]
Other Orders (List below):__________________________________________________
__________________________________________________________________________
Orders to Agencies
16 [___]
Law Enforcement to Assist A law enforcement officer from:______________________
will enforce the orders checked below:
Temporary Protective Order
Approved Board of District Court Judges May 21, 2008
Revised by Forms Committee 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 to the home or other protected places without the
officer. Law enforcement can evict you or keep you away from protected places, if needed.
17 [___]
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.
8 [___]
Guardian for your children
The court appoints an attorney to speak for the best interests of the children in this case.
Notice to the 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)).
ate: ___________ Time: ___________ [___] a.m.[___] p.m _____________________________________
Judge (printed name) _________________________________
1
D
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
Interpretación
Si usted no habla ni entiende el Inglés el
tribunal le proveeré un intérprete. Contacte
Temporary Protective Order
Approved Board of District Court Judges May 21, 2008
Revised by Forms Committee April 11, 2022
Page 6 of 7
interpreter. Contact court staff
immediately to ask for an interpreter.
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.
Temporary Protective Order
Approved Board of District Court Judges May 21, 2008
Revised by Forms Committee April 11, 2022
Page 7 of 7
