Dd Form 2873 – Fill Out and Use This PDF

Maintain in accordance with appropriate Service retention schedule.

MILITARY PROTECTIVE ORDER

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; DoDI 6400.06, Domestic Abuse Involving DoD Military and Certain Affiliated Personnel; and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): To inform the service member and the protected person that the commanding officer is issuing an order to the member prohibiting contact or communication with the protected person or members of the protected person's family or household and directing that the member take specified actions that support, or are in furtherance of, the prohibition.

ROUTINE USE(S): Information may be disclosed to departments and agencies of the Executive Branch of government in performance of their official duties relating to coordination of family advocacy programs, medical care and research concerning child abuse and neglect, and spouse abuse; to the Attorney General of the United States or his authorized representatives in connection with litigation, or other matters under the direct jurisdiction of the Department of Justice; to law enforcement officials to protect the life and welfare of third parties; see each applicable Military Service system of records notice for a complete listing of routine uses: A0608-18 DASG, Army Family Advocacy Program Files, https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN- Article-View/Article/570082/a0608-18-dasg/; N01752-1, Family Advocacy Program System, https://dpcld.defense.gov/Privacy/SORNsIndex/ DOD-wide-SORN-Article-View/Article/570332/n01752-1/; F044 AF SG Q, Family Advocacy Program Record, https://dpcld.defense.gov/ Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569871/f044-af-sg-q/; and DMDC 01, Defense Manpower Data Center Data Base, https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/OSDJS/DMDC-01.pdf?ver=2019-04-18-091612-550.

DISCLOSURE: Voluntary; however, failure to disclose/verify information will not delay either the issuance of the order or the enforceability of the order.

1a. DATE MPO ISSUED

1b. SELECT ONE: INITIAL MPO

MODIFICATION TO EXISTING MPO

2. SUBJECT SERVICE MEMBER

a. MILITARY SERVICE:

b. RANK

c. LAST NAME

FIRST NAME

MI

d. SEX

e. UNIT

f. INSTALLATION

g. DOB (YYYYMMDD)

h. HEIGHT

i. WEIGHT

j. EYE COLOR

k. HAIR COLOR

l. Race:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

m. EAS (YYYYMM)

n. OTHER DISTINGUISHING FEATURES (Scars, marks, tattoos, etc.)

o. DRIVER'S LICENSE NUMBER

p. STATE OF ISSUANCE

q. VEHICLE INFORMATION (Plate Number/State/Make/Model/Year)

r. PASSPORT NUMBER

s. SSN

t. OTHER ID

3.PROTECTED PERSON (Omit any information from item 3 that, if known to the subject service member in item 2, could endanger the protected person).

a. RANK/CIVILIAN

b. LAST NAME

FIRST NAME

MI

c. SEX

d. DRIVER'S LICENSE NUMBER

e. STATE OF ISSUANCE

f. OTHER ID

g. UNIT

h. INSTALLATION

i. DOB (YYYYMMDD)

j.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Race:

Maintain in accordance with appropriate Service retention schedule.

4. THE PROTECTED PERSON HAS ALSO BEEN ISSUED THE FOLLOWING COURT ORDERS

a. Civil protection order issued (Date)	Court,	, in	County,
State of
			Property Settlement
b. Civil protection order issued (Date)	Court,	, in
County, State of
			Custody and/or Visitation
c. Civil protection order issued (Date)	Court,	, in
County, State of
			Restriction on Firearms
d. Civil protection order issued (Date)	Court,	, in	Possession
County, State of
5. INFORMATION SUPPORTING ISSUANCE OF THIS MILITARY PROTECTIVE ORDER

7.As a Commanding Officer with jurisdiction over the above-named service member, I find that there is sufficient reason to conclude the issuance of a protective order is warranted in the best interest of good order and discipline. It is hereby ordered that (place initials in the appropriate portions):

INITIALS	a. The above-named service member is restrained from assaulting, threatening, abusing, harassing, following, interfering with, or
	stalking the protected person and/or the additional listed protected parties.
INITIALS	b. The above-named service member is restrained from initiating any contact or communication with the above-named protected
	person either directly or through a third party. For purposes of this order, the term "communication" includes, but is not limited to,
	communication in person, or through a third party, via face-to-face contact, telephone, in writing by letter, data fax, electronic mail
	or via the internet or social media. If the protected person initiates any contact with the service member, the service member must
	immediately notify me regarding the facts and circumstances surrounding such contact.
	c. The above-named service member shall remain at all times and places at least			feet away from the above-named
	protected person and additional protected person's family or household including, but not limited to, residences and workplaces.
	Additional protected persons includes the following individuals:
	NAME	DOB (Date of	SEX	RACE
		Birth) (YYYYMMDD)

	Maintain in accordance with appropriate Service retention schedule.
INITIALS	f. The service member has visitation or custody rights of the child or children named:
INITIALS	g. The protected person has temporary exclusive custody of the child or children named:
INITIALS	h. The above-named service member will attend the following counseling:
INITIALS	i. The above-named service member will surrender his/her government weapons custody card at the time of issuance of
	this order.
INITIALS	j. The above-named service member will dispose of his/her personal firearm(s) that are located or stored on the
	installation at the time of issuance of this order.
INITIALS	k. The above named individual will comply with any applicable law requiring him or her to dispose of his or her and
	privately owned firearms and ammunition and provide information that this order has been carried out.
INITIALS	l. Exceptions to this order will be granted only after an advance request is made to me and approved by me.
INITIALS	m. Other specific provisions of this order:
8. DATE OF REVIEW (Upon review, the order may be modified or terminated)			9. MILITARY POLICE REPORT/ORIGINATING AGENCY CASE #
10. NATIONAL CRIME INFORMATION CENTER (NCIC) PROTECTIVE ORDER FILE (POF)
a.		b.		c. DATE PLACED IN NCIC
ORI		NCIC#

11. DURATION: This is a NON-EXPIRING ORDER

The terms of this order shall be effective until modified or rescinded in writing by me.

ENFORCEABILITY: Violation of this order shall constitute a violation of Article 90 of the Uniform Code of

Military Justice.

a. COMMANDING OFFICER’S SIGNATURE	b. DATE (YYYYMMDD)

12. I hereby acknowledge receipt of a copy of this order with such redactions as are appropriate and attest that I understand the terms and conditions it imposes on me.

a. SERVICE MEMBER’S SIGNATURE	b. DATE (YYYYMMDD)	c. TIME ORDER SERVED

DISTRIBUTION:

Service member

Protected person (custodial parent of protected child)

Service member's local personnel file

Installation Law Enforcement for entry in the National Crime Information Center (NCIC)

Maintain in accordance with appropriate Service retention schedule.

INSTRUCTIONS

Complete as follows: Sections 1-8 and 11 are to be completed by the subject service member's Commanding Officer. Section 12 is to be completed by the subject Service member and Sections 9 & 10 are to be completed by law enforcement.

Note: Appropriate redaction should be used with the protected person's information before a copy of this form is provided to the service member subject. The service member subject should NOT be given the protected person's social security number.

Section 1: Issuance or Modification of Order 1a-b. Self-explanatory.

Section 2: Service Member Data

2a-l. Self-explanatory.

2m. Provide EAS (End of Active Service) date.

2n. Self-explanatory.

2o-t. Provide information of an acceptable form of government identification, to include:

driver's license, state ID card, passport or naturalization number. The social security number is required when the Service Member does not have other acceptable identification.

Section 3: Protected Person

3a-c. Self-explanatory.

3d-f. Driver's license, state ID card, passport or naturalization number are acceptable forms of identification. 3g-j. Self-explanatory.

Section 4: Protected Person Court Orders

4a-d. Provide information of current civil orders.

Section 5: Information Supporting Issuance of Military Protective Order

Avoid identifying anonymous sources and victim information that might endanger protected person, if known to the subject service member.

Section 6: Reasons for issuance of Order 6a. Self-explanatory.

6b. Check each applicable box that correlates with comments in item #5.

Section 7: MPO Orders

7a-m. Initial each applicable order and/or requirement.

Section 8: Date of Review

Self-explanatory.

Section 9: Military Report Number

Self-explanatory.

Section 10: National Crime Information Center (NCIC) Protective Order File (POF)

10a. Originating Agency Identifier (ORI) - Self-explanatory.

10b. National Crime Information Center (NCIC) - Self-explanatory.

10c. Self-explanatory.

Section 11: Commanding Officer's Signature

a-b. Self-explanatory.

Section 12: Service Member's Signature

a-c. Self-explanatory.