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STATE OF SOUTH DAKOTA COUNTY OF ______________ DOMESTIC

) ) ) STALKING PERMANENT

IN CIRCUIT COURT _________ JUDICIAL CIRCUIT

EX PARTE TEMPORARY

ORDER FOR PROTECTION
TPO NO. _____________________

MODIFICATION

PETITIONER
First Middle Last

PETITIONER IDENTIFIERS:
Date of Birth of Petitioner

By (name and DOB):__________________________ _____________________________________________ On behalf of a minor child by parent/guardian.

Other Protected Persons (name and DOB):________ ________________________________________________

___________________________________________
(See also 2B Additional Orders.)

V.
RESPONDENT
First Middle Last

SEX EYES

RESPONDENT IDENTIFIERS: RACE HEIGHT WEIGHT HAIR DATE OF BIRTH STATE EXPDATE

Relationship to Petitioner: ________________________________________________ __________________________________________ Respondent's Address:
__________________________________________________ __________________________________________________ __________________________________________________

DRIVERS LICENSE #

Distinguishing Features: ________________________________________________ __________________________________________

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, making threats of abuse, 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 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-091I (Domestic Modification of Permanent Order) Rev. 05/08

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ADDITIONAL FINDINGS:

This matter came before this Court on this day and the following parties appeared personally: Petitioner Petitioner's Attorney ______________________ Other ____________________ Respondent Respondent's Attorney ___________________ Other ____________________ 1) This Court FINDS that, without admitting to the allegations in the Petition, the Respondent waives further hearing, findings of fact, and conclusions of law, and stipulates to the entry of an Order of Protection on the terms specified below. 2) Having considered the evidence presented and any affidavits and pleadings on file, this Court FINDS: A. That jurisdiction and venue are properly before this Court; B. That the above-named Petitioner and Respondent are "family or household members" within the meaning of SDCL 25-10-1(2); C. By a preponderance of the evidence that "domestic abuse" as defined by SDCL 25-10-1(1) has occurred; and D. That the Respondent had actual notice of the hearing and an opportunity to participate. E. That the Motion to Modify is granted and modified terms incorporated herein.
ADDITIONAL ORDERS:

1) The Respondent is excluded from the Petitioner's residence listed in 2C. 2) That the Respondent shall not come within a distance of ___________ from the following persons and places: A. The Petitioner personally B. The following minor children named as other protected persons: Name Date of birth Relationship ___________________________ ___________ _______________________________ ___________________________ ___________ _______________________________ ___________________________ ___________ _______________________________ C. The Petitioner's residence(street/apt)_______________________________________________ (city)_______________________________, (state) _______ (zip) _________-_______ D. The Petitioner's place of employment (street)________________________________________ (city)_______________________________, (state) _______ (zip) __________- _______ E. Other places (street/apt) , (state)_______ (zip) (city) (street/apt) (city) , (state)_______ (zip) (street/apt) (city) , (state)_______ (zip) This distance restriction applies unless otherwise specified in this order. 3) The Petitioner shall have temporary custody of the minor child(ren), whose names are: _________ ______________________________________________________________________________ 4) Temporary visitation for the respondent with the minor child(ren) named above shall consist of: Existing order in File #_____________________ Supervised at _____________________ Jurisdiction: South Dakota South Dakota tribe Other State ____________ Other Other Visitation: ______________________________________________________________ _______________________________________________________________________________

Form UJS-091I (Domestic Modification of Permanent Order) Rev. 05/08

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5)

The Respondent shall pay temporary: child support in the amount of $ a month starting on continuing until further order of the Court; Child support shall be paid to: Office of Child Support Enforcement Kneip Building 700 Governors Drive Pierre, SD 57501

and

spousal support in the amount of $ a month starting on and continuing until further order of the Court. Spousal support shall be paid to the Clerk of Courts Office in the county this order was filed. 6) Phone calls, emails, third party contact, including correspondence, direct or indirect, are not permitted, to a protected person, except as follows: _________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 7) Respondent is ordered to immediately turn over all weapons and ammunition to local sheriff. 8) Other relief as follows:______________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ AND IT IS FURTHER ORDERED THAT: the Petitioner shall, immediately upon the granting of this Order, deliver two copies of this Order to the sheriff of this county. One copy shall be personally served by the sheriff upon the Respondent, unless personal service has been acknowledged below. DATED / / . Service of this order is authorized on any day including Sunday.

Judge Attest: By: , Clerk of Courts , Deputy NOTICE OF ENTRY OF ORDER AND ACKNOWLEDGMENT OF PERSONAL SERVICE I acknowledge receipt of a copy of this Order of Protection. _______________________________________ Petitioner ___________________________________________ Respondent

UNDER A PERMANENT PROTECTION ORDER: You may be subject to the following federal laws: (1) Effective immediately, you may not possess, carry, ship or transport any firearm or ammunition that has been transported in interstate or foreign commerce while this Protection Order is in effect. Title 18 United States Code Section 922(g)(8). (2) If you violate this Protection Order and are convicted of an offense of domestic violence, you may be forbidden for life from possessing, carrying, shipping or transporting, any firearm or ammunition that has been transported in interstate or foreign commerce. Title 18 United States Code Section 922(g)(9). Violation of these federal laws carries a maximum penalty of ten years in prison, a $250,000 fine, or both.

Form UJS-091I (Domestic Modification of Permanent Order) Rev. 05/08

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