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Modified Protective 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: ________ 

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):  

  F

  A

  _

  R

  O

  R

 

  T

 

Modified Protective Order 

Approved Board of District Court Judges May 21, 2008 
Revised by Forms Committee April 15, 2022 

•  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. 

  [___] 

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.  

arnings:  

  W

  R

  C

  1

2  [___] 

3  [___] 

The Court reviewed the Request for Modified Protective Order, has received argument and evidence, 
and finds the original protective order listed immediately below should be modified. 

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) 

______________________________________________________________________________ 

Modified Protective Order 

Approved Board of District Court Judges May 21, 2008 
Revised by Forms Committee April 15, 2022 

 
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______________________________________________________________________________ 

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) 

______________________________________________________________________________ 

______________________________________________________________________________ 

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: _____________________________________________ 
 

Modified Protective Order 

Approved Board of District Court Judges May 21, 2008 
Revised by Forms Committee April 15, 2022 

 
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6  [___]  

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 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)  

[    ] 

 _______________________________________________________________ (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: 
__________________________________________________________________________ 

  C

 

 

  8

 

 

 

 

Modified Protective Order 

Approved Board of District Court Judges May 21, 2008 
Revised by Forms Committee April 15, 2022 

___________________________________________________________________________ 

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):____________________________________________ 

___________________________________________________________________________ 

___________________________________________________________________________ 

rders to Agencies  

15   [___] 

  O

Law Enforcement to Assist  A law enforcement officer 
from:___________________________ 
will enforce the orders checked below: 
[__]   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.  

Modified Protective Order 

Approved Board of District Court Judges May 21, 2008 
Revised by Forms Committee April 15, 2022 

 
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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)). 

The respondent can ask to dismiss the criminal provisions of this protective order within two years, 
but only if the petitioner consents to the dismissal. (Utah Code 78B-7-603(10)). 

If 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 — 

 
Date 

Signature ► 

Commissioner 

 

 

Modified Protective Order 

Approved Board of District Court Judges May 21, 2008 
Revised by Forms Committee April 15, 2022 

 
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Date 

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 __________________________________________________________     

 

Modified Protective Order 

Approved Board of District Court Judges May 21, 2008 
Revised by Forms Committee April 15, 2022 

 
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