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Here is the text we could read:

 

Request for Protective Order 
(Utah Code 78B-7-601 et seq.) 

Case Number: _____________________ District:_____ 

County: ___________________________ State:  Utah  

Judge: _______________________________________ 

1   Petitioner (person asking for protection): 

Commissioner: ________________________________ 

____________________________________________ 
First 

Middle 

Last 

This is a private record. 

ddress and phone # (to keep private, leave blank): 

___________________________________ 
Street 

___________________________________ 
City --- State --- Zip 
Phone #’s: ___________________________ 
What is your date of birth?: __________________ 

Other people protected by this order 
(relatives or people who live with you): 
Name  
 
____________________ 
____________________ 
____________________ 
____________________ 
____________________ 

Age 
 
____ 
____ 
____ 
____ 
____ 

Relationship to 
Petitioner 
_____________ 
_____________ 
_____________ 
_____________ 
_____________ 

Name and phone number of Petitioner’s attorney (if any): _________________________________________ 

   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. 

First  

Middle 

Last 

______ 

______ 

__________ 

______ 

______ 

ther Names Used _______________________ 
____________________________________ 
Relationship to Petitioner: ___________________ 
Address (street): ___________________________ 
____________________________________ 
City --- State --- Zip 

Eyes 

Hair 

Full Social Security # (if known) 

______ 

______ 

___________________________ 

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

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

Respondent’s Employer (Name and address):  
____________________________________________________________________________________ 
 

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 

 

 

 

 

 

 

 

 

 

escribe Respondent’s vehicle(s): 

Make 

Model 

Color 

License Plates 

 

 

 

 

 

 

as the Respondent used weapons or been violent in the past? [__] Yes  [__] No   If yes, describe here:   

Request for Protective Order 

Approved Board of District Court Judges May 21, 2008 
Revised by Forms Committee April 11, 2022 

Page 1 of 8 

  A

    2

 

  O

 

 

 

 

 

 

  D

  H

______________________________________________________________________________________ 
______________________________________________________________________________________ 
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: ____________________________________________ 

   What is your relationship to the Respondent? (Check all that apply) 
[__]  a.  We are married now. 
[__]  b.  We used to be married. 

Date of Divorce: _____________________________ 

[__]  c.  We live together as a couple. 
[__]  d.  We used to live together as a couple. 
[__]  e.  We are or used to be in a consensual sexual 

relationship. 

__]  f.  We live or used to live in the same home 

 [__]  g.  We are related by blood, marriage, or 

adoption as a child, parent, aunt, uncle, niece, 
nephew, grandparent, grandchild, or sibling. 
(Specify the relationship):   
 

________________________________ 
 

[__]  h.  We are expecting a child now. 

List Due Date: _________________________ 

[__]  i.   We have or had a child or children together. 

List below: 

Child’s Name 

Address 

  3

  4

  [

 
 
 
 
 
 

   Describe the most recent abuse (if any): 

a.  When did it happen? (Date):_______________________________________________________  
b.  Where did it happen? ___________________________________________________________ 

Street 

 

 

 

City 

 

 

State  

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

What police department came? ____________________________________________________  
Was anyone arrested? [__] Yes [__] No 

If yes, who was arrested? __________________________________________________________ 

What is the case number? __________________________  
Did anyone get a ticket? [__] Yes [__] No 

If yes, who got the ticket? __________________________________________________________ 
e.  Describe the abuse or domestic violence: ____________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
[__] 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?  _______________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 

Request for Protective Order 

 

Approved Board of District Court Judges May 21, 2008 
Revised by Forms Committee April 11, 2022 

Page 2 of 8 

 

 

 
 
 
 
 
 

Birth date 
(mm/dd/yyyy) 
 
 
 
 
 
 

 

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.  Were any children present when this happened? [__] Yes [__] No (If “yes,” who?)_______________ 
i.  Who else was there? ____________________________________________________________ 
j.  Was anyone hurt? ______________________________________________________________ 
k.  Other facts: ___________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 

5   Describe past abuse (if any): 

a.  When did it happen? (Date):______________________________________________________ 
b.  Where did it happen? ___________________________________________________________ 

Street 

 

 

 

City 

 

 

State  

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

What police department came? ____________________________________________________  
Was anyone arrested? [__] Yes [__] No 

If yes, who was arrested? __________________________________________________________ 

What is the case number? __________________________  
Did anyone get a ticket? [__] Yes [__] No 

If yes, who got the ticket? __________________________________________________________ 
e.  Describe the past abuse or domestic violence: ________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
[__] Check here if you need more space and attach a separate sheet of paper to this form 

6    Fear of imminent physical harm  

respondent against me.  

[  ]  Other than what I describe above, I fear there is a substantial likelihood of imminent physical harm by 

(Describe in detail why you are afraid the respondent will cause you physical harm in the immediate future.)   

________________________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 
________________________________________________________________________________ 

[  ] Check here if you need more space and attach additional pages to this form. 

7  Other Court Cases 

Request for Protective Order 

 

a.  Are you or the Respondent on probation now for domestic violence? [__]Yes [__] No (If Yes, who? _______) 
b.  Have you or the Respondent ever been involved in any other court case involving either of you or your 

Approved Board of District Court Judges May 21, 2008 
Revised by Forms Committee April 11, 2022 

Page 3 of 8 

 
 

 
 

 
 

 
 

 

 

 

children? [__] Yes [__] No (If yes, list ALL court cases below): 

Court case name 

Judge's name 

Type of case 

Person involved 

 
 
[  ]  Order of protection 
[  ]  Civil litigation 
[  ]  Petitioner   
[  ]  Respondent 

Court case number 

County and state 

[  ]  Juvenile court proceeding 
[  ]  Criminal case 

Did the judge make 
an order? 

[  ]  Yes   
[  ]  No 

Court case name 

Judge's name 

Type of case 

Person involved 

 
 
[  ]  Order of protection 
[  ]  Civil litigation 
[  ]  Petitioner   
[  ]  Respondent 

Court case number 

County and state 

[  ]  Juvenile court proceeding 
[  ]  Criminal case 

Did the judge make 
an order? 

[  ]  Yes   
[  ]  No 

Court case name 

Judge's name 

Type of case 

Person involved 

 
 
[  ]  Order of protection 
[  ]  Civil litigation 
[  ]  Petitioner   
[  ]  Respondent 

Court case number 

County and state 

[  ]  Juvenile court proceeding 
[  ]  Criminal case 

Did the judge make 
an order? 

[  ]  Yes   
[  ]  No 

Court case name 

Judge's name 

Type of case 

Person involved 

 
 
[  ]  Order of protection 
[  ]  Civil litigation 
[  ]  Petitioner   
[  ]  Respondent 

Court case number 

County and state 

[  ]  Juvenile court proceeding 
[  ]  Criminal case 

Did the judge make 
an order? 

[  ]  Yes   
[  ]  No 

   

 

 

c.  Fill out below if any child listed on the first page of this form is involved in any other court case, like 

adoption, juvenile, or custody, or has been investigated by the Division of Child and Family 
Services. 

Type of Case 

County and State 

Court or DCFS case number 
(if you know it) 

 

 

Request for Protective Orders 
I ask the court for the following orders. 
(Choose all that apply.) 

 

 

 

Request for Protective Order 

 

Approved Board of District Court Judges May 21, 2008 
Revised by Forms Committee April 11, 2022 

Page 4 of 8 

 

       

8 

[___] 

9 

[___] 

Personal Conduct Order the Respondent not to commit, try to commit or threaten to commit 
any form of violence against me 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 the Respondent not to contact, phone, mail, e-mail, or communicate with 
me and the people listed on the first page of this form in any way, either directly or indirectly 
except as allowed by the parent-time provisions of the temporary protective order. 

10  [___] 

Contact for Mediation Order that the Respondent may contact me only during mediation 
sessions for our divorce or custody case that are scheduled with a Court Qualified Mediator.  

11  [___] 

Stay Away Order the Respondent to stay away from:  

[  ]  a.  Stay at least _______________________________ (distance) from me. 

[  ]  b.  Stay away from my  

Home: ___________________________________________________________ (address) 

Work : ___________________________________________________________ (address) 

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

School: __________________________________________________________ (address) 

The respondent  [  ] does  [  ] does not  go to the same school as me. 

Place of worship: __________________________________________________ (address) 

The respondent  [  ] does  [  ] does not  attend the same place of worship as me. 

If you work, go to the same school, or attend the same place of worship as the respondent, the 
court cannot order the Respondent to stay away from those places. Give information the court 
should consider about potential or necessary interactions with the Respondent in those settings.  

 

 

[  ]  c.  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) 

Request for Protective Order 

 

Approved Board of District Court Judges May 21, 2008 
Revised by Forms Committee April 11, 2022 

Page 5 of 8 

 

The respondent  [  ] does  [  ] does not  attend the same place of worship as the people 
listed on the first page of this form. 

[  ]  d.  Other (specify): __________________________________________________________________________ 

No Guns or Weapons – Order the Respondent not to use, possess, have, or buy a gun or 
firearm or any of these weapons: _______________________________________________ 

Property Control – Order that only I can use, control and possess the following:  
[__]   a. Home at (address):  

_________________________________________________________________________ 

[__]   b. Car, truck or other essential personal belongings (describe): _________________  

_________________________________________________________________________ 

_________________________________________________________________________ 

14  [___] 

Property Control  Order the Respondent  

[  ]  Not to interfere with or change my phone, utility or other services.  

[  ]  To maintain existing wireless phone contracts or accounts. 

No Harming Pets – Order the Respondent to not physically injure or threaten to injure a pet 
that is: 
[  ] a.  Owned or kept by me. Also order the Respondent to not take possession of my pet. 

[  ] b.  Owned or kept by the Respondent. 

Transfer Wireless Phone Number(s) Order the Respondent and the wireless service 
provider to transfer my current wireless phone number(s) to a new account of my choice. 
•  The Respondent is the account holder for the following wireless phone number(s):  

_____________________________________________________________________ 
•  The number(s) are assigned to phones that are primarily used by me, or by people who will 

• 

live with me while the protective order is in effect. 
I will have full financial responsibility for each wireless phone number, beginning on the 
day of transfer. This includes monthly service costs and costs for any mobile device 
associated with the wireless phone number(s). 

•  A wireless service provider may apply standard requirements for account establishment to 

me when transferring financial responsibility. 

17  [___] 

Child Custody & Parent-time Orders  

Give temporary custody of these minor children I have with the respondent to   

[  ] me   

[  ] __________________________________________________________ (name of person 
other than the Respondent): 
_________________________________________________________________________ 
_________________________________________________________________________ 

Give the Respondent parent-time as follows: _____________________________________ 

Request for Protective Order 

 

Approved Board of District Court Judges May 21, 2008 
Revised by Forms Committee April 11, 2022 

Page 6 of 8 

2  [___] 

3  [___] 

  1

  1

5  [___] 

 

 

  1

 

 

16  [___] 

 

_________________________________________________________________________ 
_________________________________________________________________________ 
_________________________________________________________________________ 
_________________________________________________________________________ 

f you asked for a No Contact Order above, who can communicate only parent-time 
information to the Respondent? (Name):_________________________________________ 

No Alcohol or Drugs Order the Respondent not to use alcohol or illegal drugs before or 
during visitation. 

Supervised Visitation Provide the Respondent with supervised parent-time as follows: (list 
name and phone number of supervising agency or person):________________________  

Travel Restrictions Order the Respondent not to take the children listed above out of the 
state of Utah. 

Child Support, Spousal Support and other Expenses -- Order the Respondent to: 
[__]   a.  Pay $ ______ / month in child support according to Utah Child Support Guidelines. 
[__]   b.   Pay $ ______ / month in spousal support. 
[__]   c.  Pay child support by withholding from the Respondent’s earnings. (Utah Code  62A-11-4 

[__]   d.   Pay 50% of the minor children’s childcare expenses.  
[__]   e.   Pay 50% of the minor children’s medical expenses, including premiums, deductibles 

and 62A-11-5)  

and co-payments.  

[__]   f.  Pay $ _________ for the minor children’s medical expenses related to the abuse 

and $ _________ for my medical expenses related to the abuse.   

  I

 

18  [___] 

19  [___] 

20  [___] 

21  [___] 

22  [___] 

Other Assistance Needed (List below any other orders needed to protect you and other 
protected people listed on page 1 of this form):_____________________________________ 

__________________________________________________________________________ 

__________________________________________________________________________ 

I also ask for these Orders to Agencies: 

23   [___] 

Law Enforcement to Assist Order a law enforcement officer 
from:______________________________ to enforce the orders checked below: 
[__]   a.  Help me gain and keep control of home, car or other personal belongings.  
[__]   b.  Help me obtain custody of the children. 
[__]   c.  Help the [__] Respondent or [__] me remove essential personal belongings from the 

home.  

24  [___] 

 
Investigate Possible Child Abuse Refer this matter to the Division of Child and Family 
Services for review and possible investigation of child abuse.  

5  [___] 

Guardian for your children Appoint an attorney to speak for the best interests of the children 
in this case. 

Request for Protective Order 

Approved Board of District Court Judges May 21, 2008 
Revised by Forms Committee April 11, 2022 

Page 7 of 8 

  2

 

 

 

 

The Petitioner must read and sign below: 

I swear that: 

• 
• 

• 
• 

I am the Petitioner and I have read this Request for 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). 

 
Date 

Signature ► 

Printed Name 

 

 

 

 

 

Request for Protective Order 

Approved Board of District Court Judges May 21, 2008 
Revised by Forms Committee April 11, 2022 

Page 8 of 8

Request for Protective Order

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Utah state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from legacy.utcourts.gov (2023-03)
Page(s): 8
Fields(s): 195
Average fields per page: 24
Reading Level: Grade 7
LIST Grouping(s): GO-00-00-00-00.

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Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

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page_field__34 was page_4_field_2 (0.36 conf)
school was school (0.31 conf)
attend_place_worship was the_respondent_does_does_not__attend_the_same_place_of_worship_as_me (0.37 conf)
consider_necessary was should_consider_about_potential_or_necessary_interactions_with_the_respondent_in_those_settings (0.40 conf)
page_field__35 was page_4_field_6 (0.36 conf)
page_field__36 was page_4_field_7 (0.36 conf)
page_field__37 was page_4_field_8 (0.36 conf)
users1_address_line_one was address (1.00 conf)
stay_least was a_stay_at_least (0.42 conf)
b_stay_away was b_stay_away_from_my (0.30 conf)
stay_away_first_page_form was c_stay_away_from_the_people_listed_on_the_first_page_of_this_form_at_their (0.35 conf)
place_worship was place_of_worship (0.29 conf)
page_check__48 was page_4_check_4 (0.26 conf)
page_check__49 was page_4_check_5 (0.26 conf)
page_check__50 was page_4_check_6 (0.26 conf)
respondent_go_school was the_respondent_does_does_not__go_to_the_same_school_as_me (0.40 conf)
page_check__51 was page_4_check_8 (0.26 conf)
first_page_form was the_first_page_of_this_form (0.39 conf)
page_check__52 was page_4_check_10 (0.26 conf)
page_check__53 was page_4_check_11 (0.26 conf)
page_check__54 was page_4_check_12 (0.26 conf)
guns_weapons_use_gun was no_guns_or_weapons_order_the_respondent_not_to_use__possess__have__or_buy_a_gun_or (0.41 conf)
page_field__38 was page_5_field_1 (0.36 conf)
page_field__39 was page_5_field_2 (0.36 conf)
essential_personal_describe was b__car__truck_or_other_essential_personal_belongings__describe (0.44 conf)
page_field__40 was page_5_field_4 (0.36 conf)
property_control_order was property_control__order_the_respondent (0.36 conf)
account_phone_number was the_respondent_is_the_account_holder_for_the_following_wireless_phone_number_s (0.32 conf)
page_field__41 was page_5_field_7 (0.36 conf)
respondent was other_than_the_respondent (0.41 conf)
page was page_6_of_8 (0.42 conf)
specify was d_other__specify (0.33 conf)
listed_first_page_form was listed_on_the_first_page_of_this_form (0.39 conf)
page_check__55 was page_5_check_2 (0.26 conf)
change_utility_services was not_to_interfere_with_or_change_my_phone__utility_or_other_services (0.35 conf)
existing_wireless_accounts was to_maintain_existing_wireless_phone_contracts_or_accounts (0.40 conf)
also_order_take_possession was a_owned_or_kept_by_me__also_order_the_respondent_to_not_take_possession_of_my_pet (0.46 conf)
b_owned_kept_respondent was b_owned_or_kept_by_the_respondent (0.37 conf)
me was me (0.45 conf)
page_check__56 was page_5_check_8 (0.26 conf)
contact_communicate_time was if_you_asked_for_a_no_contact_order_above__who_can_communicate_only_parent_time (0.41 conf)
drugs_order_use_illegal was no_alcohol_or_drugs_order_the_respondent_not_to_use_alcohol_or_illegal_drugs_before_or (0.48 conf)
respondent_parent_follows was supervised_visitation_provide_the_respondent_with_supervised_parent_time_as_follows_list (0.35 conf)
month_spousal_support was month_in_spousal_support (0.37 conf)
month_according_guidelines was month_in_child_support_according_to_utah_child_support_guidelines (0.39 conf)
co_payments was and_co_payments (0.40 conf)
and was and (0.41 conf)
assistance_needed_orders was other_assistance_needed__list_below_any_other_orders_needed_to_protect_you_and_other (0.37 conf)
protected_people_page_form was protected_people_listed_on_page_1_of_this_form (0.34 conf)
help_gain_keep_personal was a_help_me_gain_and_keep_control_of_home__car_or_other_personal_belongings (0.42 conf)
page_field__42 was page_6_field_10 (0.36 conf)
signed was signed_at (0.36 conf)
city_state_country was city__and_state_or_country (0.47 conf)
signature_date was date (1.00 conf)
users1_signature was signature (1.00 conf)
page_field__43 was page_7_field_4 (0.36 conf)

We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

state_utah
district
page_field__1
page_field__2
private_record
first
street
relationship
age
page_field__3
users1_address_line_two
petitioners1_name
page_field__4
page_field__5
page_field__6
page_field__7
page_field__8
phone
page_field__9
page_field__10
phone_petitioner_attorney
page_field__11
describe_know_unknown
page_field__12
page_field__13
page_field__14
wt
ht
users1_birthdate
race
sex
middle
names_used
full_social_security_known
hair
eyes
page_field__15
address_street
distinguishing_like_etc
page_field__16
page_field__17
expires
page_field__18
respondent_name_address
respondent_probation_parole
yes_list_name_probation_parole
af_f
specify_relationship
child_children_together
page_field__19
users1_address_state
yes
page_field__20
page_field__21
page_field__22
no
describe_abuse_domestic_violence
space_separate_sheet_paper
f_person_say_make_afraid
request_protective_order
page_check__1
page_check__2
page_check__3
anyone_arrested
police_department_came
yes_got_ticket
page_check__4
page_check__5
page_check__6
page_check__7
page_check__8
page_check__9
page_check__10
page_field__23
h_children_present_happened
yes_describe
else
j_anyone_hurt
k_facts
page_field__24
page_field__25
page_field__26
page_field__27
page_field__28
page_field__29
page_field__30
page_field__31
describe_past_abuse_violence
check_need_additional_form
page_field__32
person_use_threaten_gun_weapon
page_check__11
page_check__12
page_check__13
respondent_probation_violence
page_check__14
page_check__15
page_check__16
page_check__17
page_check__18
likelihood_imminent_harm
page_check__19
page_field__33
children
page_check__20
order_protection
civil_litigation
page_check__21
respondents1_name
page_check__22
page_check__23
page_check__24
page_check__25
page_check__26
page_check__27
page_check__28
page_check__29
page_check__30
page_check__31
page_check__32
page_check__33
juvenile_court_proceeding
criminal_case
page_check__34
page_check__35
page_check__36
page_check__37
page_check__38
page_check__39
page_check__40
page_check__41
page_check__42
page_check__43
page_check__44
page_check__45
page_check__46
page_check__47
stay_away_order_respondent
home
page_field__34
school
attend_place_worship
consider_necessary
page_field__35
page_field__36
page_field__37
users1_address_line_one
stay_least
b_stay_away
stay_away_first_page_form
place_worship
page_check__48
page_check__49
page_check__50
respondent_go_school
page_check__51
first_page_form
page_check__52
page_check__53
page_check__54
guns_weapons_use_gun
page_field__38
page_field__39
essential_personal_describe
page_field__40
property_control_order
account_phone_number
page_field__41
respondent
page
specify
listed_first_page_form
page_check__55
change_utility_services
existing_wireless_accounts
also_order_take_possession
b_owned_kept_respondent
me
page_check__56
contact_communicate_time
drugs_order_use_illegal
respondent_parent_follows
month_spousal_support
month_according_guidelines
co_payments
and
assistance_needed_orders
protected_people_page_form
help_gain_keep_personal
page_field__42
signed
city_state_country
signature_date
users1_signature
page_field__43

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02