Case Number:_______________ District:_____ 
County:_____________________________   State: Utah 
Judge:  __________________________________________  
Commissioner: __________________________________   

Other people protected by this order  

Name 

Age 

Relationship to 
Petitioner 

 
 
 
 
 

 

 
 

 

 

 
 
   
 
 
 
 
 
 
   
 
 

Phone # 

 
 
 
 
 

 
 
 
 
 

 

Middle  

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

Last 

 

 
  City  

Phone #:  

State 

Zip 

Petitioner’s attorney (if any):  
 

Name 

Respondent (person Petitioner is protected from) 
 

etitioner (protected person)  

  P

 

ating Violence 
Protective Order 
 

  D

Dating Violence Protective Order 

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First  
Other names used:  
Address (street):  

Middle  

Last 

Eyes 

Hair 

Describe Respondent: 

  Sex 
 

 

 

Race  Date of Birth 

Ht 
 

Wt 

 

 

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

 

Social Security # 
(only the last 4 numbers) 
 

State               Zip   

 
Driver’s license issued by (State): 

 Expires:  

 

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’s attorney (name):__________________________________________ 
[  ] Petitioner 
[  ] Respondent 
[  ] Respondent’s attorney (name):________________________________________ 
[  ] Other (name) ____________________________________________________________________ 

The court reviewed the Request for Dating Violence Protective Order and:  

[  ] Received argument and evidence,  
[  ] Accepted the stipulation of the parties, 
[  ]  Entered the default of the Respondent for failure to appear, 
[  ] Other: _________________________________________________________________________ 

The court finds: (1) The Respondent and the Petitioner are or have been dating partners as defined in 
the statute, (2) the Respondent has engaged in dating violence or abuse or there is a substantial 

 

City 
 

  T

pproved Board of District Court Judges June 
20, 2014 / Revised by Forms Committee April 
11, 2022 
 

  A

 

 
 
 
 
 

 

 

 

 
 
 
 

 

 

 
 
 

 

likelihood that the Respondent will engage in dating violence or abuse. 

The Court orders the Respondent to obey the following provisions initialed by the judge: 

1  [___] 

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

2  [___] 

No Contact Order   Do not directly or indirectly contact, phone, text, mail, e-mail, or 
communicate in any way with the Petitioner or any person listed on page 1 of this form.  

3  [___] 

Stay Away Order    

[  ]  Respondent is ordered to stay at least ___________ feet from petitioner. 

[  ]  Respondent is ordered to stay away from: 

[  ]  Petitioner’s home: 

___________________________________________________________________ 
(Street, City, State, ZIP) 

[  ]  Petitioner’s work:  

___________________________________________________________________ 
(Street, City, State, ZIP) 

[  ]  Respondent works at the same place as the petitioner. Respondent is not 
ordered to stay away from this location, but the following restrictions apply 
when petitioner and respondent are both there:    

[  ]  Petitioner’s school:  

___________________________________________________________________  
(Street, City, State, ZIP) 

[  ]  Respondent attends the same school as the petitioner. Respondent is not 
ordered to stay away from this location, but the following restrictions apply 
when petitioner and respondent are both there:  

 

 

[  ]  These places, which the petitioner goes to often: 

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

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

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

Dating Violence Protective Order 

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pproved Board of District Court Judges June 
20, 2014 / Revised by Forms Committee April 
11, 2022 
 

  A

 

  [___] 

No Guns or Other Weapons 

The Court finds by clear and convincing evidence that your use or possession of a weapon 
poses a serious threat of harm to the Petitioner or other family or household members 
designated on page 1 of this order. You cannot possess, have, or buy a gun or firearm or any 
of these weapons:  

_______________________________________________________________________________________________________ 

  [___] 

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. 

6   [___] 

Other:  

 _______________________________________________________________________________________________________ 

 _______________________________________________________________________________________________________ 

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.A. 
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. 

pproved Board of District Court Judges June 
20, 2014 / Revised by Forms Committee April 
11, 2022 
 

Dating Violence Protective Order 

Page 3 of 4 

  4

  5

 

 

  A

 

 

Name of person 

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

Name of person 

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

Name of person 

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

 

 

 

 

 

 

[  ]  Other (specify):  

Warnings to the Respondent:  
•  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.  

•  A violation of this order is a Class A Misdemeanor, punishable by up to 364 days in jail and a fine. 

This protective order expires in three years, on this date 

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

________________________ (date) 

(Utah Code 78B-7-405) 

 

--- The Court fills out below --- 

Signature ► 

Commissioner 

Signature ► 

Judge 

 

 

 

 

By signing here, the Respondent approves the form, and accepts service of this Protective Order and 

--- The Respondent fills out below --- 

waives the right to be personally served. 

espondent’s Address:  

______________________________________________________________________________________________ 
Street                                                                  City                                                    State                        Zip 

espondent’s Signature  

 _________________________________________________ 

 
Date 

 
Date 

  

  R

  R

 

  A

pproved Board of District Court Judges June 
20, 2014 / Revised by Forms Committee April 
11, 2022 
 

Dating Violence Protective Order 

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