Request to Modify Protective
Order
/ Case Number: ______District:_____
County:______State: Utah
Judge: ______
Commissioner:______
1Petitioner(protected person):This is a private record.
Other people protected by this order
(relatives or people who live with you):
First Middle Last
/ Name / Age / Relationship to Petitioner
Address and phone # (to keep private, leave blank):
| / ______/ _____ / ______

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
* Required. If you do not know, write unknown.
Sex* / Race* / Date of Birth* / Ht. / Wt.
First / Middle / Last / ______/ ______/ ______/ ______/ ______
Other Names Used ______
______/ Eyes
______ / Hair
______ / Full Social Security # (if known)
______
Relationship to Petitioner: ______Address(street): ______/ Distinguishing features (like tattoos, scars, limp, etc.)
______
______
City --- State --- Zip / ______
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, relatives, friend, hangouts, etc.) / Best times to find at this address / Phone number

Describe Respondent’s vehicle(s):

Make / Model / Color / License Plates

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: ______

3What 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):

4Why 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:

[X]Order the Respondent to go to a court hearing

[X]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.

5Pleasechange Number _____in the current order to:

6Pleasechange Number _____in the current order to:

7Pleasechange Number _____in the current order to:

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 declare under criminal penalty under the law of Utah that everything stated in this document is true.
Signed at ______(city, and state or country).
Signature ►
Date / Printed Name
Request to Modify Protective Order / Approved Board of District Court Judges May 21, 2008
Revised February 6, 2019 / Page 1 of 3