Request to Modify Protective Order

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					                                                                                                          Case Number: ________________ District:_____
 Request to Modify Protective
                                                                                                          County: _______________________ State: Utah
 Order                                                                                                    Judge: __________________________________
                                                                                                          Commissioner: ___________________________

1 Petitioner (protected person):                                                                                                  This is a private record.
                                                                                                Other people who need protection (relatives or people
                                                                                                who live with you):
 First                                  Middle                        Last                      Name (Initials only if                Relationship to
 Address and phone # (to keep private, leave blank):                                                                       Age          Respondent
                                                                                                    under 18)
                                                                                                __________________                       |
                                                                                                                                      ____     ______________
   Street                                                                                       __________________                    ____ /   ______________
                                                                                                __________________                    ____     ______________
   City                                             State             Zip                       __________________                    ____ /   ______________
 Phone #:                                                                                       __________________                    ____     ______________
 Name and phone number of Petitioner’s attorney (if any):


2 Respondent (person you need to be protected from):                                            Describe Respondent:
                                                                                                   Sex          Race       Date of Birth       Ht.           Wt.

 First                                 Middle                                   Last                                                       Social Security #
                                                                                                     Eyes              Hair
 Other names used:                                                                                                                       (only the last 4 numbers)
 Relationship to Petitioner:

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

         City                          State                          Zip                       Driver’s license issued by (State):               Expires:

 Respondent’s Employer (Name and address):
 _________________________________________________________________________________________________
 Other places to find Respondent (other work                                   Location type (work,          Best times to find at             Phone number
 locations, relatives, friend, hangouts, etc. – include                                                          this address
                                                                                relative, friend, etc.)
 city/state/zip on each address, if possible)




 Describe Respondent’s vehicle(s):
                  Make                                            Model                                     Color                          License Plates




                                                                                 Approved Board of District Court Judges May 21, 2008
 Request to Modify Protective Order                                                                            Revised April 20, 2012       Page 1 of 3
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 kind of protective order do you have now? (Check one, and attach a copy of your protective order to this form.)
      Temporary Protective Order, signed by this court on (date):
      Protective Order, signed by this court on (date):

4    Why do you want this order changed?




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

Please, Judge, I am asking you to:
           Order the Respondent to go to a court hearing
           Issue a new (modified) order to replace the current order. Please make the modified order the same as
           the current order except for the change(s) below.
5      Please change Number _____ in the current order to:




        ___________________________________________________________________________________________

6      Please change Number _____ in the current order to:




        ___________________________________________________________________________________________

7      Please change Number _____ in the current order to:



                                                      Approved Board of District Court Judges May 21, 2008
Request to Modify Protective Order                                                  Revised April 20, 2012   Page 2 of 3
        ___________________________________________________________________________________________

The Petitioner must read and sign below:
       I swear that:
            I am the Petitioner and I have read this Request to Modify 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.
            The statements in this Request are true and correct to the best of my knowledge.
            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 have not included any non-public information in this document.


          Date: ____________________________   Petitioner’s signature:


Clerk or Notary Public fills out below:
          Subscribed and sworn to before me on (date):                             in                                        County, Utah
                                                        , Clerk / Notary Public

          Clerk or Notary’s Signature:    __________________________________________________




                                                        Approved Board of District Court Judges May 21, 2008
Request to Modify Protective Order                                                    Revised April 20, 2012   Page 3 of 3

				
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