Form Ujs-091f - Order For Protection - 2016

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STATE OF SOUTH DAKOTA
)
IN CIRCUIT COURT
)
COUNTY OF ______________
)
_________ JUDICIAL CIRCUIT
DOMESTIC
STALKING
ORDER FOR PROTECTION
EX PARTE TEMPORARY
PERMANENT
_____________________
TPO NO.
MODIFICATION
PETITIONER
PETITIONER IDENTIFIERS:
First
Middle
Last
Date of Birth of Petitioner
By (name and DOB):____________________________
Other Protected Persons (name and DOB): ___________
_____________________________________________
_____________________________________________
On behalf of a minor child by parent/guardian.
__________________________________________
(See also 2B Additional Orders.)
V.
RESPONDENT
RESPONDENT IDENTIFIERS:
SEX
RACE
HEIGHT
WEIGHT
First
Middle
Last
EYES
HAIR
DATE OF BIRTH
Relationship to Petitioner:
DRIVERS LICENSE #
STATE EXPDATE
_____________________________________________
_____________________________________________
Distinguishing Features:
Respondent’s Address:
_____________________________________________
__________________________________________________
_____________________________________________
__________________________________________________
__________________________________________________
CAUTION:
Weapon Involved
THE COURT FINDS:
That it has jurisdiction over the parties and subject matter, and the Respondent has been provided with reasonable notice
and opportunity to be heard, and that in the case of an ex parte order, the Respondent will be provided with reasonable
notice and opportunity to be heard sufficient to protect the Respondent’s due process rights.
THE COURT ORDERS:
That the Respondent is restrained from acts of abuse and physical harm, attempted or threatened abuse and
physical harm, stalking or harassment.
That the Respondent is restrained from contact with the Petitioner by any direct or indirect means except as
authorized in this order.
Additional findings and orders are on the following pages.
This order shall be effective
, through
Month/Day
Year
Month/Day
Year
Or if a permanent protection order is issued, until that order is served.
Only this Court can change this order.
VIOLATION OF THIS PROTECTION ORDER IS A CRIMINAL OFFENSE.
WARNING TO RESPONDENT: This order shall be enforced, even without registration, by courts of any state, the District of
Columbia, any U.S. Territory, and may be enforced by Tribal Lands (18 U.S.C.§2265). Crossing state, territorial, or tribal boundaries
to violate this order may result in federal imprisonment (18 U.S.C. §2262).
Form UJS-091F (Domestic Permanent Order of Protection) Rev. 07/01/16
1

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