Ex Parte Order Of Protection Form Page 2
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3The Respondent is prohibited from initiating any contact with the victim(s) including but not
limited to physical presence, telephonic, electronic, oral, written, visual, or video. Respondent also
shall not use a third party to contact the victim(s) except by legal counsel or as authorized by law or
court order.
The Respondent is excluded from the Petitioner’s residence and the immediate vicinity thereof.
Petitioner’s Address:_______________________________________________________________________(or)
The Petitioner’s address is excluded from notice to the Respondent.
The Respondent is prohibited from the following places:
Petitioner’s Workplace: _________________________________________________________________
School: _______________________________________________________________________________
Other (Identify):
______________________________________________________________________________
______________________________________________________________________________________________
____________________________________is awarded temporary custody of the minor child(ren):
(Names)_______________________________________________________________________________
Any law enforcement officer with jurisdiction is ordered to assist the Petitioner in gaining
possession of the dwelling, and/or to otherwise assist in execution or service of the Order of
Protection.
Other Orders: ___________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
If the parties (or other persons named herein) are subject to the jurisdiction of another court (i.e. through a
divorce or paternity action), upon proper notice and the opportunity to be heard, said court may amend the
terms of this Order as appropriate.
On this ____ day of _________________, 20____, IT IS SO ORDERED.
CIRCUIT JUDGE
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