Order of Proc ection

- [J Amended Order

Case# (the clerk fills this in):

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I5 D I -1 ?f DIV 1ZL-I

0 Pe:titioner kS under 18

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:county(lffl

HAMILTON ~- l t_~ ~ (} 1

In the _ _.: :C.!.!.IR.!. :C: :. : U.:. :I:.:. T_ _ _ _ Court of

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2015 SEP 21 PH 2: 50

Petitioner (person needing protection)

If Petitioner is under 18, insert child's name if filed on behalf of an unemancipated person (someone under 18 years of age} pursuant to
TCA 36-3-602. This Request is being made by
'' \ .' '! i \~?q (J(;h_i!cl's'p?reht or 0 legal guardian or 0 a caseworker.

Pi

first

last

Petitioner's Children under 18 Protected by this Order:

Name
1

'

'

RS:CEI___VName
I= O

Relat1onsh1p to Res!'~!Taent

Age

Age

Relationship to Respondent

-- - - - - - - - - - - ----7S'IEHP'r'23
-1 Zu+a-- - - - - - - - - - - -

2. ____________________________________~La~ri~m
~~rco~
u"
nt
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o;M IUI n l -~ U II 1'-V

Respondent s Information (person you want to be protected from):

She.,\~
first

t~bS

date of birt/1 (MMtDD/YYYY}

last

city

street address

Respondent's Employer:

CA ;t~

':fDu.>erS

middle

zip

state

\,)"' btlvuJ"'
Employers phone #

Employers name

Describe Respondent:
Sex
OMale
1i(1=ema!e

Race

Hair

Eyes

Height- Weight - SSN - Other

~hite

0 Black:

0 Brown

Height

0 Asl afl

0 Grey

0 Hazel

0 Black

'Rj31ond

Social Sec. #
(If known)

~Blue

0 Hispanic

OBald

liii;:,Green

OOther:

D Brown

0 Grey

0 Other:

0 Other:

We have a chiid together.

We are relatives, related by adoption, or are/were in-laws. (Specify):

We are the children of a person whose relationship is described above (Specify):
The Re-rrdent has stalked me.

recJ.s

1:1

l-\.

0..( ...-

I 13 0

We live together or used to live together.

~ We are dating, used to date, or have had sex.

&- Other:

Weight

Scars/Special Features

Petitioner's relationship to the Respondent (Check all that apply):

0 We are married or used to be married.

D
;8

.;'' (,

--

The Respondent has sexually assaulted me.

~ (c...S"';>vn t" .J.

i'

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Warning!

Findings About Abuse:

1 _ The Court has jurisdiction over the parties and this case. The Respondent was given
reasonable notice of the hearing and an opportunity to be heard.
2.

0 Weapon
mvolved
O
Has or owns a weapon

Based on the information in the Petition, and the hearing held, the court finds that the Respondent:

Did the things listed in the Petition and the court adopts these as facts and incorporates them by reference, AND/OR

Did the following things:

3.

Respondent has specifically: (check all that apply):

Abused/Threatened to Abuse
the D Petitioner AND

06110/11

0 Sexually Assaulted

~alked

Petitioner's Minor Children.

Order of Protection

""\W

page 1

Fi~ings

about the minor children of the parties: (check one):

The-"Court has jurisdiction over custody for the child(ren) of the parties because his/her/their home state is
l'"".enness~e.

The Court has temporary emergencyjurlsdic"tion over custody for the children of the parties listed above because
they are in Tennessee now, and they (or lh~ Petitioner) were at risk. (If another state has jurisdiction over child
custody under UCCJEA, this Court's tempOrary jurisdiction will end on
or when the other

state's Court makes an order.)

Findings About Firearms:

The Respondent (check all that apply):
0

Has no firearms

r/ Has firearms that he/she must give to someone else who is allowed to have them (TCA 36-3-625).
0

Has firearms that are registered under the National Firearms Act and must be either transferred to a responsible
third party, or locked in a safe or other secure container to which the Respondent does not have access. A state
or federal agency must give its approval before the firearms are turned in.
Has a federal firearms license {FFL) or is a responsible party under an FFL, and has firearms under that FFL that
qualify as business inventory, and (check one):
0
There is no responsible party listed on the FFL other than the Respondent in this case. The Respondent
must turn in or transfer all firearms inventory under his/her control to a separate FFL holder who is legally
allowed to have firearms.
0
There is another responsible party listed on the FFL other than the Respondent in this case. This Order
does not require the Respondent to turn in or transfer the firearms inventory.

Other Findings:
0

Petitioner is a party to a lease or rental agreement and that continuing to reside in the rented or leased premises
may jeopardize the life, health and safety of the petitioner or the petiti::mer's children.

The Courl orders Respondent to:

0
0
0

Obey all orders on this form.

Not abuse or threaten to abuse Petitioner or Petitioner's minor children.
Not stalk or threaten to stalk Petitioner or Petitioner's minor children.

OVler Orders to the Respondent (Check all that apply):

ri

No Contact
You must not come/about the Petitioner (including coming by or to a shared residence) for any purpose and
must not contact IE Petitioner AND 0 Petitioner's children, either directly or indirectly, by phone, email,
messages, text messages, mail or any other type of communication or contact.

'StayAway
/You must stay away from the

00 Petitioner's home

0 Petitioner's workplace 0 Children's home and workplace.

~ PefsonaiConduct-

You must not cause intentional damage to the Petitioner's {or Petitioner's children's) property or interfere with
the utilities at their home(s).
You must not hurt or threaten to hurt any animals owned or kept by the Petitioner/Petitioner's children.

Counseling/Substance Abuse Programs

You must go to the following program(s) and give the court proof th3t you have gone, participated and have made
progress in this program (contact information): - - - - - - - - - - - - - - - - - - - - - - -

Parenting Time
0
0

06/10/11

The Petitioner will have custody of the minor child(ren) in this case.
You will have parenting time with your minor child(ren) at the folpwin9. times:

Order of Protection

page 2

....P

Your parenting time will be supervised by: _ _ _ _ _ _ _ _ _ _ at: - - ' - - - - - - - - - - E~change of the children will take place at and will happen as follows:

The person in charge of getting the minor children to and from visitation will be:
D Mom
D Dad
D Other ( n a m e ) : - - - - - - - - - - - - - - to the visits
D Mom
D Dad
D Other (name):
from the visits

0 Child Support $ __!each

0
0

(month/week, etc) beginning

(date).

This is the guideline amount. See the attached DHS Child Support Worksheet.
This is not the guideline amount and is a deviation from the guideline amount. The Court has considered
the best interest of each child in this case, and finds that guideline support would be unjust or
inappropriate in this case.

0 Other:-----------------------------Payment method:
0 Pay the Petitioner directly by the
day of each month. (the court finds that this does not
endanger the Petitioner or the Petitioner's minor children and it is not a violation to send payment only with
no notes or comments to the Petitioner)
0 Take payment to this Court Clerk's Office. You will also have to pay a clerk fee of _ _% on each
each month.
payment. The additional clerk fee amount is $
0 Support payments will be 0 withheld from your paycheck (Contact the Central Collection and
or 0 shall be sent directly to Central Collection
Disbursement Unit at 800-838-6911 by
Disbursement Unit at Central Child Support Receipting Unit, P. 0 . Box 305200, Nashville, TN 37229.

0 Petitioner Support $ _ _! each month.

Payment method:
0

0
0

Pay the Petitioner directly by the

day of each month. (The court finds that this does not
endanger the Petitioner or the Petitioner's minor children and it is not a violation to send payment only with
no notes or comments to the Petitioner)
Take payment to this Court Clerk's Office. You will also have to pay a clerk fee of _ _% on each
each month.
payment. The additional clerk fee amount is $
Payment will be
0 withheld from your paycheck (Contact the Central Collection and Disbursement Unit at 800-838-6911
by
(date)
0 shall be sent directly to Central Collection Disbursement Unit at Central Child Support Receipting Unit,
P. 0. Box 305200, Nashville, TN 37229.

0 Control of all Types of Property

0

Petitioner only 0

and/or Petitioner's children are the only ones who can live in the property at:

-----------------------------------~ddros~

D You must move out immediately from (address): _______....:__________-'---0 You must provide suitable alternate housing for the Petitioner by (date) :
, 20
.
0 You must pay to the petitioner all costs, expenses and fees pertaining to the petitioner's breach of a lease or
rental agreement for residentia l property in the amount o f - - - - - - - - - - - - - 0 Only the Petitioner can use, control , and possess the following property, things, and animals:

06/10/ 11

If the parties shared a residence, Respondent can obtain his/her clothing and personal effects such as
medicine as follows: (List items to be obtained and process as approved by local law enforcement
personnel)-----------------------------------

Order of Protection

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--------------~--~~~--------------------------------------------------------

lor~ers to the Respondent about Firearms:

0

You must not have, or attempt to have, receive or attempt to receive or in any other way get any firearm while
t]lis or any later protective order is in effect.

You must transfer all firearms in your possession within 48 hours to any person who is legally allowed to have
them.

You must fill out and file a Firearms Declaration within 1 business day of transferring your firearms. You may
take more than 1 business day to file this form only if the Court gave you a later deadline. (You can get the
Firearms Declaration form from the Court Clerk's Office or at www.tncourts.gov.)

If a state or federal agency approves it, your weapons that are registered under the National Fir-earms Act
must be either transferred to a responsible third party, or placed in a locked safe or other secure container to
which you do not have access.

If your Firearms Declaration shows that you have a federal firearms license (FFL), and that you are the only
responsible party listed on that FFL, you must transfer all firearms inventory under your control to a separate
FFL holder or another responsible party.

D Costs, fees and litigation taxes

You must pay all court costs (Petitioner's costs and your costs), lawyer fees, and other fees or taxes related to
this case.

This Order takes effect immediately upon signing.

This Order starts today, (date): .....,.,.,"'d"~..-o---""'-...!f-""'-=-'=
This Order ends (date): ___....oQ~~~--<::1-~~~~

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tb
D

In 1 year. The Petitioner may sk to continue the Order.

In 5 years (1st violation of current PO)
In 10 ears (2nd or more violation of current PO
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Date;~:l/7 ,.lv/slfme: :J.''f(, ,.g=~~-------~-~"=~" ---~---~

-~~ ~fJUdQeOfChancellor
7

Da.m.
Proof of Service
The Respondent was served on (date): _0 9~
Time:
by (check one):

Personal service
u LJ.S. mail, prepaid postage to the Respondent's last known address
D U.S. mail per TCA 20-2-215 and 20-2-216 (The Respondent does not live in Tennessee)

'1/5

Lf:oo '-

~-

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02
D

Te
.

!__

erk certifie~a
copy f this Order was forwarded to 911 and local law enforcement
n"able~ d the Respondent's address were made, but there is no known ad~ress at this time.

~- ~

Signature of

06/10/11

Serv~ _,.c

L CS 0

Dep~ty

Server's title (check one): D Clerk _D

Clerk
uthonzed Officer D Attorney

page4

Order of Protection

..

Warnings to Responder~t:

Th~s

"

Order is valid everywhere in the U.S.

If you travel to another state, territory or tribal land, with the intention of disobeying this Order, you can be ..
charged with a federal crime. The courts of any U.S. state, the District of Columbia, all tribal lands, and U.S.
territories, must enforce this Order, even if the Order is not registered. (18 U.S.C. 2262, 2265)

No Guns, Firearms
You must not have any firearm while this Order is in effect. You cannot own, possess, have, buy or try to
buy, receive or try to receive, or in any other way get any firearm or ammunition.
You must legally transfer, sell, or turn in any firearm that you have within 48 hours. Transfers are <;:>nly legal
if the person you transfer to is allowed to have firearms. You may get your firearms back when the Order of
protection ends.

You will face separate charges if you disobey this Order

You may face separate, Class A misdemeanor charges if: :

You do not transfer your firearm(s) legally by the deadline

You have a firearm while the Order is in effect

The penalty for each violation is up to 11 months and 29 days in jail and a fine of up to $2,500.
There may be other charges if domestic violence isinvolved. If you disobey this Order on purpose,
you may face up to 10 days in jail and a $50 fine for each violation. You may also have to pay a civil
penalty of up to $50 for each violation.

If you do not transfer, sell, or turn in any firearm you may face Class A misdemeanor charges and
you may also be charged with a federal crime.

tLy_ou hurt or Lry to hurt anyone while this Order, probation or diversion is in effect, you may face
charges for aggravated assault, a Class C felony. (TCA 39-13-102(c), 36-3-610)

Only the Court can change this Order

Neither you nor the Petitioner can agree to change this Order. Even if the Petitioner attempts to contact you
or agrees to have contact with you, you must obey this Order. If you do not, you can be jailed for up to 11
months and 29 days and fined up to $2,500.

To the Petitioner:
You may ask any government agency or utility provider to keep private any
information that could be used to locate you, such as addresses, phone numbers,
and/or social security number. To do so, give a copy of this Protective Order to
the Records Department ofthe agency or utility.
(TCA 10-7-504(a){l5-!6))

06/10/11

Order of Protection

page 5