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Petitioners Date of Birth Mmddyyyy Form

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DR- - 1 of 7 Final Order of Protection Amended Order Case No. Circuit Court, Div. County: Petitioner/Plaintiff , Arkansas This Order is Effective Until: Petitioner’s Date of Birth (mm/dd/yyyy) Race Sex Minor Children Protected under this Order First Middle Last Versus Respondent Identifiers Respondent/Defendant First Middle Last Address: ___________________________________ ___________________________________________ ___________________________________________ Employer: __________________________________ CAUTION: Distinguishing Characteristics: ______________________ Respondent possesses a firearm _________________________________________________ Respondent has history of extreme violence _________________________________________________ d.o.b. d.o.b. d.o.b. d.o.b. Sex Race DOB mm/dd/yyyy Ht. Wt. Eyes Hair SS# Phone # DL # or other ID # Pursuant to Federal law, this Order shall be enforced by law enforcement officers in all states, territories, districts and tribal lands regardless of whether this Order of Protection is registered locally. DR- - 2 of 7 Relationship Identifiers: Current or former spo uses Parents of child(ren) in common Live together Current or past dati ng relationship Other Relative (Explain)______________________ THE COURT HEREBY FINDS AND ORDERS: ☒ That there is jurisdiction over the parties a nd subject matter, and the Respondent has been provided with proper notice and the opportunity to be heard; ☒ That the victim(s) is (are) in immediate and present danger of domestic abuse; ☒ That Respondent presents a credible threat to the physical safety of a person named in the order of protection as a family member or household member, a child of the family or household member, or a child of the respondent or enjoined party; and therefore, ☒ An Order of Protection is hereby granted pursuant to the terms herein. A hearing on this matter was held on the _______________ day of ________________________ , 2 __________ The Petitioner appeared pro se. __________ ____________________________________ _______________ The Petitioner was represented by counsel. ___________________________________________________ The Respondent ap p eared pro se. The Respondent was represented by counsel. __________________________________________________ The Respondent failed to appear despite proper notice. _______ ___________________________________ __________________________________________ ☒The Respondent is restrained from committing any cr iminal act against the victim(s) including, but not limited to: acts of violence or Domestic Abuse, A.C.A. §9-15-103(3); Harassment A.C.A. §5-71-208; Harassing Communications A.C.A. §5-71-209; Stalking A.C.A. §5-71-229; or Terroristic Threatening A.C.A. §5-13-301. ☒The Respondent is prohibited from initiating any contact with the victim(s) including, but not limited to, phys ical presence, telephonic, electronic, oral, written, visu al, or video. Respondent also shall not use a third party to contact the victim(s) except by legal c ounsel 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. ___________________________________________ ________________________________________________ DR- - 3 of 7 The Respondent is also prohibited from the following places: _______ _______________________________ _______________________________________________________________________________________ Petitioner’s Workplace: __________________________________________________________________________ Schools: _______________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Other (Identify): ________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________ is awarded temporary custody of the minor child(ren) for the duration of order or until future orders shall be issued from a Court with jurisdiction over the parties: (Children’s Names) ___________________________________________________________________________ _______________________________________________________________________________________________ Visitation with regard to the minor child(ren) is established as follows: __________________________________ _______________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ DR- - 4 of 7     is ordered to pay child support to through the ☐ Circuit Clerk’s Office ☐ Child Support Clearinghouse in the amount of $ _____________ pe r ___________________, plus any administrative fees as they come due with said payments to be gin on _____________________. This amount is according to the Child Support Chart based upon the payor’s income of __________________ per ____________________________. This amount ☐ does / ☐ does not (check one) deviate from the Child Support Chart. (If the amount deviates from the Chart, the justification below in the “Other Orders” section.) _______________ is ordered to pay spousal support in the amount of $ _________ per ___________, beginning on ______________________ ___________________________ The spousal support shall be paid until _________. Method of payment shall be: ___________________________________________________________________ ___________________________________________________________________________________________ Note: As there is an expiration date on all Orders of Protection, future matters regarding Child Support, Alimony and Visita tion should be handled through another Domestic Relations case (i.e. divorce, paternity, or through the Office of Child Support Enforcement). A law enforcement officer with jurisdiction is orde red to assist the Petitioner in gaining possession of the dwelling, and/or to otherwise assist in execution of the Order of Protection. A law enforcement officer with jurisdiction is ordere d to serve the Order of Protection on the Respondent. A law enforcement officer with jurisdiction is ordered to assist the Petitioner in obtaining his or her personal effects from the dwelling upon proper and timely request of the Petitioner. A law enforcement officer with jurisdiction is ordered to assist the Respondent in obtaining his or her personal effects from the dwelling upon proper and timely request of the Respondent. DR- - 5 of 7 Other Orders: ☒ Respondent is hereby assessed an additional cost of twenty-five dollars ($25.00) to be paid through the Circuit Clerk’s office. The Circuit Clerk shall remit sa id fee to the Administration of Justice Funds Section within the Department of Finance and Administration for deposit as special revenues into the Domestic Violence Shelter Fund. Petitioner and/or the minor children in Petitioner’s care ar e the primary users, but not the account holder, of the following wireless telephone numbers: ____ ________________________________________________. Respondent is prohibited from terminating these accounts. An order transferring the billing responsibility for and rights to the wireless telephone numb er(s) will be filed separately herein. 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 th e 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/DISTRICT JUDGE DR- - 6 of 7 WARNINGS TO RESPONDENT (1) A violation of the order of protection is a Class A misdemeanor carrying a maximum penalty of one (1) year's imprisonment in the county jail or a fine of up to one thousand dollars ($1,000), or both; (2) A violation of an order of protection under this sec tion within five years of a previous conviction for a violation of an order of protection is a Class D felony; (3) It is unlawful for an individual who is subject to an order of protection or convicted of a misdemeanor of domestic violence to ship, transport, or possess a fir earm or ammunition under 18 U.S.C. §922(g)(8) and (9) as it existed on January 1, 2019; (4) A conviction of violation of an order of prot ection under this section within five (5) years of a previous conviction for violation of an order of protection is a Class D felony; (5) A person who is a respondent or an enjoined party is restrained from harassing, stalking, or threatening a person named in an order of protection as a family or household member, a child, of the family or household member, or a child of the respondent or enjoined party; (6) A person who is a respondent or an enjoined pa rty is restrained from engaging in other conduct that would place a person named in an order of protection as a family or household member, a child of the family or household member, or a child of the respondent or enjo ined party in reasonable fear of bodily injury; and (7) A person who is a respondent is prohibited from using, attempting to use, or threatening the use of physical force against the person named in the order of protection as a family or household member, a child of the family or household member, or a child of the respondent or enjoined party which would reasonably be expected to cause bodily injury -Crossing state, territorial, or tribal boundaries to violate this Order may result in federal imprisonment pursuant to 18 U.S.C. §2262. NOTICE TO LAW ENFORCEMENT -In the event that any law enforcement officer has proba ble cause to believe that the Respondent named in the above Order has violated this Order and has verificati on of this Order the officer, may, without a warrant arrest the violator whether the violation was in or outside the officer’s presence. See A.C.A. §9-15-207(f). -A law enforcement officer SHALL NOT arrest a Peti tioner for the violation of an Order of Protection issued against a Respondent. See A.C.A. §9-15-207(e). -This Order of Protection is enforceable in every c ounty of this state by any court or law enforcement officer. See A.C.A. §9-15-207(g). -This Order is entitled to full faith and credit in any jurisdiction of the United States. See 18 U.S.C. §2265. DR- - 7 of 7 PROOF OF SERVICE Case # _________________________________________ Court Date _________________________ ___ SERVED : Date Time Place ____________________________ Attempts Made: List only date and time 1) ____________________________ 2) _____________________________ 3)__________________________ ___________________________________________________________________________________________ Served On (Print Name) Manner of Service ___________________________________________________________________________________________ Served By (Print Name) Title Badge # DECLARATION OF SERVER I declare, under penalty of perjury under the laws of the State of Arkansas, that the foregoing information contained in the proof of service is true and correct. Executed on _____________________ __________________________________ Date Signature of Server _______________________________________________ Address of Server

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