equest for Dating Violence 
Protective Order (Utah Code 78B-7-404) 

  Petitioner (person asking for protection):  
 

 

Middle  

First  
Address and phone #: (to keep private, leave blank) 
 
  Street 

Last 

 

 
  City  

State 

Zip 

Case Number: ________________  District:_____ 
County:  _______________________   State: Utah 
Judge:  __________________________________  
   Commissioner:  ___________________________  

 

 

 

This is a private record. 

Other people to be protected by this order  
(relatives or people who live with you): 

Name 

Age 

Relationship to 
Petitioner 

 
 

 

 
 
 
 
 

 
 
 
 
 

 
 
   
 
 
 
 
   
 
 
 
 

 
 
 
 
 

 

 
 
 
 
 

 

 

 
 
 
 

Phone #s:  
Name and phone number of Petitioner’s attorney (if any):  
Are you 18 years of age or older?[__]   Yes      [__]    No 
If you are under 18 years of age, have you ever been: emancipated by a juvenile court order?  __]   Yes    [__]    No    
Married?  [__] Yes    [__] No     

 

 

 

ote:  The court cannot issue a dating violence protective order if any of the following apply: 

You and the Respondent are or were married. 
You and the Respondent lived together or used to live together as a couple. 
You and the Respondent have a minor child or children together. 

f any of those apply do not proceed further with this action.  You may wish to investigate whether you qualify for a 
Cohabitant Abuse Protective Order. 

2   Respondent (person you need to be protected from): 

 

Describe Respondent 
* Required. If you do not know, write unknown. 

Sex* 

Race* 

Date of Birth* 

Ht. 

Wt. 

Middle 

Last 

______ 

______ 

__________ 

______ 

______ 

ther Names Used _______________________ 
____________________________________ 

Eyes 

Hair 

Full Social Security # (if known) 

______ 

______ 

___________________________ 

Address (street): ___________________________ 

____________________________________ 
City --- State --- Zip 

Distinguishing features (like tattoos, scars, limp, etc.) 
_________________________________________________ 
_________________________________________________ 

Driver’s license issued by (State):______ Expires: _________ 

Is the Respondent 18 years of age or older?  [__]   Yes      [__]    No 
If the Respondent is under 18 years of age has the Respondent ever been: emancipated by a juvenile court 
order?[__]   Yes     [__]    No    Married?  [__]   Yes    [__] No     

Respondent’s Employer (Name and address): 

 ________________________________________________________________________________________________ 

Request for Dating Violence Protective Order 

Page 1 of 7 

Approved Board of District Court Judges May 13, 
2013 /  Revised by Forms Committee April 11, 
2022 

 

  R

  1

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• 
• 
• 

  I

  

 

First  

  O

Other places to find Respondent (work, 
relatives, friend, hangouts, etc. – include 
city/state/zip on each address, if possible) 

Location Type (work, 
relatives, friend, 
hangouts, etc) 

Best times to find at 
this address 

Phone number 

Describe Respondent’s vehicle(s): 

Make 

Model 

Color 

License Plate 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the Respondent have a history of violence during which the Respondent used a weapon?[__] Yes  [__] 

No   If yes, describe here:  

_______________________________________________________________________________________

______________________________________________________________________________________ 

Is the Respondent on probation or parole?   [__]   Yes    [__]   No   If yes, list the name of the probation/parole 

agency, the officer, and the telephone number here:  ____________________________________________ 

3  Under Utah Code § 78B-7-404, the court cannot issue a protective order unless the court 

determines that you and the Respondent have or had a dating relationship.  In making this 
determination, the court will consider the following factors: 

the length of your relationship with the Respondent; 
the nature and the frequency of the interactions between you and the Respondent, including   

a.  whether you and the Respondent developed interpersonal bonding above a mere casual fraternization: 
b. 
c. 
communications indicating that you and the Respondent intended to begin a dating relationship; 
d.  the ongoing expectations you and/or the Respondent had with respect to the relationship; 
e.  whether the statements or conduct by you and the Respondent demonstrated an affirmation of your 
relationship to others; and 
f.  whether other reasons exist that support or detract from a finding that a dating relationship exists. 

Using those factors, explain why you believe you and the Respondent have or had a dating relationship. 

 

Approved Board of District Court Judges May 13, 
2013 /  Revised by Forms Committee April 11, 
2022 

Request for Dating Violence Protective Order 

Page 2 of 7 

   

 

 

 

 

 

 

 

       

4  Describe the most recent abuse or dating violence: 

a.  When did it happen? (Date):  

 

Street  

b.  Where did it happen?  
 
c.  Did the police come?  [__]   Yes  [__]   No 
d.  If the police came, answer these questions: 
  What police department came?  
  What is the case number?  
e.  Describe the abuse or dating violence:  

  City 

 State 

   Was anyone arrested?  
   Did anyone get a ticket? 

[__]   Yes  [__]   No  
[__]   Yes  [__] No 

[__]   Check here if you need more space and attach a separate sheet of paper to this form. 

f.  What did the other person do or say to make you afraid?  

Approved Board of District Court Judges May 13, 
2013 /  Revised by Forms Committee April 11, 
2022 

 

Request for Dating Violence Protective Order 

Page 3 of 7 

 

 

 

 

 

 

 

 

 

 

 

 

 

                               

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

g.  Did the other person use or threaten to use a gun or other weapon? [__] Yes  [__]   No  (If yes, describe 

any weapons the Respondent owns and how they were used against you): 

h.  Who else was there?  

i.  Was anyone hurt?  

j.  Other facts: 

5  Describe past abuse (If none, skip to 6) 

a.  When did it happen? (Date):  

b.  Where did it happen?  

c.  Did the police come?  [__]   Yes  [__]   No 
d.  If the police came, answer these questions: 

Street  

  City 

 State 

What police department came?  

   Was anyone arrested?  

[__] Yes  [__] No  

What is the case number?  

   Did anyone get a ticket? 

[__] Yes  [__] No 

e.  Describe the past abuse or dating violence:  

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

[  ] Check here if you need more space and attach a separate sheet of paper to this form. 

6  Other Court Cases 

a.  Have you or the Respondent ever been involved in any other court case?  
      [__]   Yes  [__]   No (If yes, list ALL court cases below): 

Type of Case 

County and State 

Court Case # 
(Not police report #) 

 

 

 

 

Did the judge 
make an order? 
[__] You [__] Respondent  [__] Yes   [__] No 

Person involved 

[__] You [__] Respondent  [__] Yes   [__] No 

Approved Board of District Court Judges May 13, 
2013 /  Revised by Forms Committee April 11, 
2022 

 

Request for Dating Violence Protective Order 

Page 4 of 7 

Type of Case 

County and State 

 

 

 

Court Case # 
(Not police report #) 

Did the judge 
make an order? 
[__] You [__] Respondent  [__] Yes   [__] No 

Person involved 

I am asking the Court to:   
7 

8 

9 

[__]  Stay Away   

[__]  Personal Conduct     Order the Respondent not to commit, try to commit or threaten to commit any 
form of abuse or violence against me or any person listed on page 1 of this form. This includes 
stalking, harassing, threatening, physically hurting, or causing any other form of abuse or violence.  

[__]  No Contact     Order the Respondent not to directly or indirectly contact, phone, text, mail, email, or 

communicate in any way with me or any person listed in item 1.  

[__]  Order the respondent to stay at least ___________ feet from me. 

[__]  Order the respondent to stay away from: 

[  ]  My home: _______________________________________________________________ 

(Street, City, State, ZIP) 

(If you and respondent go to the same place of work or school the court cannot order respondent to 
stay away from those places. However, you can ask for restrictions at those locations, such as distance 
to stay away, areas, or periods of time not to be present.) 

[  ]  My work:  _______________________________________________________________ 

(Street, City, State, ZIP) 

[  ]  Respondent does not work at the same place as me. 

[  ]  Respondent works at the same place as me and I ask for the following restrictions at 

that location because:   

[  ]  My school:  ______________________________________________________________  

(Street, City, State, ZIP) 

[  ]  Respondent does not attend the same school as me. 

[  ]  Respondent attends the same school as me and I ask for the following restrictions at 

that location because:  

 

 

[  ]  These places, which I go to often: 

 _________________________________________________________________ 
(Name of place, Street, City, State, ZIP) 

__________________________________________________________________ 
(Name of place, Street, City, State, ZIP) 

Request for Dating Violence Protective Order 

Page 5 of 7 

Approved Board of District Court Judges May 13, 
2013 /  Revised by Forms Committee April 11, 
2022 

 

[  ]  These places, which the people listed below  (listed on page 1) go to often:  

 

 

 

 

 

 

Name of person 

Description of place and 
address  
(Street, City, State, ZIP) 

ame of person 

Description of place and 
address  
(Street, City, State, ZIP) 

ame of person 

Description of place and 
address  
(Street, City, State, ZIP) 

  N

  N

[  ]  Other (specify):  

 

0 

[__]  No Guns or Weapons    Order the Respondent not to use, possess, have, or buy a gun or firearm 
or any of these weapons: __________________________________________________________ 

1     [__]   No Harming Pets    Order the Respondent to not physically injure or threaten to injure a pet that is: 
 

[  ]  Owned or kept by me. Also order the Respondent to not take possession of my pet. 

             

 

             

[  ]  Owned or kept by the Respondent. 

12 

[__]  Other Relief (specify):  

_____________________________________________________________________________ 

_____________________________________________________________________________ 

13  Temporary Orders    Make immediate, temporary orders without prior notice to the Respondent,     

pending a hearing in this case. 

14  Final Orders  Make the temporary orders final after the hearing. 

Approved Board of District Court Judges May 13, 
2013 /  Revised by Forms Committee April 11, 
2022 

Request for Dating Violence Protective Order 

Page 6 of 7 

  1

  1

   

 

The Petitioner must read and sign below: 

I swear that: 

I am the Petitioner and I have read this Request for Dating Violence Protective Order. 

I understand it is a serious crime to lie to get a Protective Order. If I lie, I can be charged with 
a felony, punishable by up to 5 years in prison.  

I believe I have the right to the protective orders I have asked for in this Request. 

I am not using this Request to harass the Respondent or to abuse the judicial process. 

I declare under criminal penalty under the law of Utah that everything stated in this document is true. 

Signed at ______________________________________________________ (city, and state or country). 

Signature ► 

Printed Name 

 

 

• 

• 

• 

• 

 
Date 

     

 

 

Approved Board of District Court Judges May 13, 
2013 /  Revised by Forms Committee April 11, 
2022 

Request for Dating Violence Protective Order 

Page 7 of 7