Utah > Statewide > Protective Orders And Civil Stalking
Request For Protective Order - Utah
| Request For Protective Order Form. This is a Utah form and can be used in Protective Orders And Civil Stalking Statewide . |
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Request for Protective Order Case Number: ________________ District:_____ County: _______________________ State: Utah Judge: __________________________________ Commissioner: ___________________________ This is a private record. 1 Petitioner (person asking for protection): First Middle Last Address and phone #: (to keep private, leave blank) Street Other people protected by this order (relatives or people who live with you): Name (Initials only if Relationship to Age Petitioner under 18) City State Zip Phone #s: Name and phone number of Petitioner's attorney (if any): What is your date of birth? If you are under 16 years old, have you ever been married or emancipated by a court? Yes No 2 Respondent (person you need to be protected from): Describe Respondent: Sex Race Date of Birth Hair Ht. Wt. First Middle Last Other names used: Relationship to Petitioner: Address (street): City State Zip Eyes Social Security # (only the last 4 numbers) 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, Best times to find at relatives, friend, this address hangouts, etc) Phone number Describe Respondent's vehicle(s): Make Model Color License Plates Request for Protective Order Approved Board of District Court Judges May 21, 2008 Revised April 1, 2012 Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Has the Respondent used weapons or been violent in the past? 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 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: f. We are relatives, in-laws, or related by adoption Specify relationship: g. We are expecting a child now. List due date: c. We live together as a couple. d. We used to live together as a couple. e. We live or used to live in the same home. Child's Initials Month and Year of Birth h. We have a child or children together (under 18 years old) List below: Address (Delete Column) 4 Describe the most recent abuse: 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? What is the case number? e. Describe the abuse or domestic violence: 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. Request for Protective Order Approved Board of District Court Judges May 21, 2008 Revised April 1, 2012 Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com f. What did the other person do or say to make you afraid? 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 i. j. Who else was there? Was anyone hurt? If "Yes,", who? k. Other facts: 5 Describe past abuse (If none, skip to 6) 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? What is the case number? e. Describe the past abuse or domestic violence: 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. Approved Board of District Court Judges May 21, 2008 Revised April 1, 2012 Request for Protective Order Page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 6 Other Court Cases 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 children? Yes No (If yes, list ALL court cases below): Type of Case County and State Court Case # (Not police report #) Person involved You Respondent You Respondent You Respondent Did the judge make an order? Yes No Yes No Yes No c. Fill out below if any child listed on page 1 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) Please, Judge, I am asking you to: Order the Respondent to go to a court hearing Make temporary (ex parte) orders, and After the hearing, make permanent the protective orders I have checked below: 7 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 in item 1 of this form. This includes stalking, harassing, threatening, physically hurting, or causing any other form of abuse. 8 9 10 No Contact Order the Respondent not to contact, phone, mail, email, or communicate with me in any way, either directly or indirectly. 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. a. My current or future: Vehicle Job School Home, premises and property (My current addresses are listed below): Home address: Work address: School address: Vehicle description: Stay Away Order the Respondent to stay away from: b. The school or childcare of the children listed on page 1 of this form. (The current school and childcare addresses are listed here): Request for Protective Order Approved Board of District Court Judges May 21, 2008 Revised April 1, 2012 Page 4 of 6 American LegalNet, Inc. www.FormsWorkFlow.com c. Other (specify): 11 No Guns or Weapons Order the Respondent not to use, possess, have, or buy a gun or firearm or any of these weapons: 12 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
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