1 Case No. __________ Dept. No. __________ 2 IN THE JUSTICE COURT OF ________________________ TOWNSHIP 3 COUNTY OF _____________________, STATE OF NEVADA 4 5 _______________________________________, Applicant, 6 vs. APPLICATION FOR A TEMPORARY AND/OR EXTENDED ORDER FOR PROTECTION AGAINST DOMESTIC VIOLENCE 7 8 ________________________________________, Adverse Party. 9 Please write or print clearly. Use black or dark blue ink. Complete this Application to the best of your knowledge. 10 11 12 Applicant states the following facts under penalty of perjury: 1. Applicant’s Date of Birth: _____________ Adverse Party’s Date of Birth: ___________ 13 Relationship: I am the __________________(for example, wife, ex-husband, girlfriend, father, 14 sister, etc.) of the Adverse Party. 15 (a) Length of relationship: _____________________. (b) Have you ever lived together? Yes No (c) Are you living together now? Yes No 16 If so, how long? _____________ 17 (d) Date of Separation: __________________________. 18 (e) We have child(ren) TOGETHER: Yes 19 these child(ren) living? _____________________________________ or No If yes, where and with whom are 20 21 2. My address is: CONFIDENTIAL. (If confidential, do not write address here) If address is not confidential, write below: 22 Address__________________________________________________________________ 23 City______________________________ State__________ Zip Code_________________ 24 I 25 _________________________________________________________________________ 26 How long have you been living in this residence? _________________________________. own rent this residence. Lease/title is held in all the following name(s): 27 28 1 American LegalNet, Inc. www.FormsWorkflow.com 1 3. Adverse Party’s address is: 2 Address________________________________________________________________ 3 City______________________________ State_________ Zip Code________________ 4 How long has the Adverse Party been living in this residence?_____________________. 5 4. My place of employment is 6 CONFIDENTIAL. (If confidential, do not write address here) If not confidential, state place(s) of employment: 7 Name of employer_________________________________________________________ 8 Address: _________________________________________Phone__________________ 9 City _____________________________ County ____________________State________ 10 Name of employer_________________________________________________________ 11 Address: _________________________________________Phone__________________ 12 City _____________________________ County ____________________State________ 13 14 Name of employer_________________________________________________________ 15 Address: _________________________________________Phone__________________ 16 City _____________________________ County ____________________State________ 17 5. Adverse Party’s employer is:________________________________________________ 18 Address: ________________________________________________Phone __________ 19 City _____________________________County ____________________State________ 20 21 6. (a) The name(s) and date(s) of birth of the minor child(ren) of whom I am the parent, appointed guardian, or who live in my home, are as follows: 22 23 NAME (first and last) 24 25 26 1. 27 28 2. DATE OF BIRTH APPLICANT’S CHILD (Yes/No) Circle one Yes Circle one Yes No No ADVERSE PARTY’S CHILD (Yes/No) Circle one Yes Circle one Yes WHO CHILD LIVES WITH No No 2 American LegalNet, Inc. www.FormsWorkflow.com 1 NAME (first and last) DATE OF BIRTH 2 APPLICANT’S CHILD (Yes/No) ADVERSE PARTY’S CHILD (Yes/No) 3 Circle one Yes Circle one Yes 3. 4 5 No Circle one Yes Circle one Yes No WHO CHILD LIVES WITH No No 6 4. 7 5. Circle one Yes No Circle one Yes No 6. Circle one Yes No Circle one Yes No 8 9 10 (b) Have you or the Adverse Party ever been awarded custody/guardianship of the minor 11 child(ren) by Court Order? Yes No 12 Who was awarded custody/guardianship? 13 By what Court? __________________________________________________________ 14 Court Case No. (if known) __________________________________________________ Applicant Adverse Party 15 16 7. Please check the appropriate box, IF YOU or the ADVERSE PARTY have ever filed a case in any court for a Divorce, Custody, Paternity, Child Support, Guardianship, 17 Order for Protection Against Domestic Violence, or Stalking/Harassment Order. Please 18 indicate when and where the case(s) was filed, and list the case number(s) if known. 19 ______________________________________________________________________________ 20 ______________________________________________________________________________. 21 22 8. (a) Has CHILD PROTECTIVE SERVICES (CPS) ever been contacted regarding any member of the household in the past year? Yes No 23 (b) Is CPS currently involved with your family? 24 Yes No If yes, give details, including the caseworker’s name: 25 ______________________________________________________________________________ 26 ______________________________________________________________________________ 27 ______________________________________________________________________________ 28 ______________________________________________________________________________. 3 American LegalNet, Inc. www.FormsWorkflow.com 1 9. (a) Does the Adverse Party possess a firearm, or does the Adverse Party have a firearm under his Yes No I don’t know 2 or her custody or control? 3 (b) Has the Adverse Party ever threatened, harassed, or injured you, the minor child(ren), or 4 anyone else with a firearm or any other weapon? Yes No I don’t know If yes, give details: 5 ______________________________________________________________________________ 6 ______________________________________________________________________________ 7 ______________________________________________________________________________ 8 ______________________________________________________________________________. 9 10 10. (a) I have been or reasonably believe I will become a victim of domestic violence committed by the Adverse Party. (b) The child(ren) have been or are in danger of becoming a victim of domestic violence 11 committed by the Adverse Party. 12 13 In the following space, state the facts that support your Application. Be as specific as you can, starting with the most recent incident. Include the approximate dates and locations, and whether law enforcement or medical personnel have been involved. 14 15 THIS APPLICATION IS A PUBLIC RECORD 16 ____________________________________________________________________________________ 17 ____________________________________________________________________________________ 18 ____________________________________________________________________________________ 19 ____________________________________________________________________________________ 20 ____________________________________________________________________________________ 21 ____________________________________________________________________________________ 22 ____________________________________________________________________________________ 23 ____________________________________________________________________________________ 24 ____________________________________________________________________________________ 25 ____________________________________________________________________________________ 26 ____________________________________________________________________________________ 27 ____________________________________________________________________________________ 28 ____________________________________________________________________________________ 4 American LegalNet, Inc. www.FormsWorkflow.com 1 ____________________________________________________________________________________ 2 ____________________________________________________________________________________ 3 ____________________________________________________________________________________ 4 ____________________________________________________________________________________ 5 ____________________________________________________________________________________ 6 ____________________________________________________________________________________ 7 ____________________________________________________________________________________ 8 ____________________________________________________________________________________ 9 ____________________________________________________________________________________ 10 ____________________________________________________________________________________ 11 ____________________________________________________________________________________ 12 ____________________________________________________________________________________ 13 ____________________________________________________________________________________ 14 ____________________________________________________________________________________ 15 ____________________________________________________________________________________ 16 ____________________________________________________________________________________ 17 ____________________________________________________________________________________ 18 ____________________________________________________________________________________ 19 ____________________________________________________________________________________ 20 ____________________________________________________________________________________ 21 ____________________________________________________________________________________ 22 ____________________________________________________________________________________ 23 ____________________________________________________________________________________ 24 ____________________________________________________________________________________ 25 ____________________________________________________________________________________ 26 ____________________________________________________________________________________ 27 ____________________________________________________________________________________ 28 PLEASE DO NOT WRITE ON THE BACKS OF ANY PAGES. 5 American LegalNet, Inc. www.FormsWorkflow.com 1 11. Have YOU ever been arrested or charged with domestic violence, or any other crime committed Yes No 2 against your spouse, partner, or child(ren)? 3 If yes, WHEN and where? 4 ______________________________________________________________________________ ______________________________________________________________________________. 5 6 12. 7 To your knowledge, has the ADVERSE PARTY ever been arrested or charged with domestic violence, or any other crime committed against his/her spouse, partner, or child(ren)? Yes 8 No I don’t know If yes, WHEN and where? 9 ______________________________________________________________________________ 10 ______________________________________________________________________________ ______________________________________________________________________________. 11 12 13. An emergency exists, and I need a TEMPORARY ORDER FOR PROTECTION AGAINST 13 DOMESTIC VIOLENCE issued immediately, without notice to the Adverse Party, to avoid 14 irreparable injury or harm. I request that it include the following relief, and any other relief the 15 Court deems necessary in an emergency situation. (Please check all the choice(s) that may apply 16 to YOU): 17 (A) Prohibit the Adverse Party, either directly or through an agent, from threatening, physically injuring, or harassing me and/or the minor child(ren). 18 (B) Prohibit the Adverse Party from any contact with me whatsoever. 19 (C) Exclude the Adverse Party from my residence and order the Adverse Party to stay at 20 least 100 yards away from my residence. 21 (D) Obtain law enforcement assistance to 22 ___________________________________________________________________or 23 accompany me to the following residence, to accompany the Adverse Party to the following residence, _____________________________________________________________________ 24 to obtain personal property. 25 (E) Grant temporary custody of the minor child(ren) to me. 26 (F) Order that custody, visitation, and support of the minor child(ren) remain as ordered in 27 the Decree of Divorce/Order entered in Case Number _______________________ in the 28 ________________________________Court of the State of ______________________ . 6 American LegalNet, Inc. www.FormsWorkflow.com 1 (G) Order the Adverse Party to stay at least 100 yards away from the minor child(ren)’s 2 school(s), or day care(s), located at 3 (If confidential, do not write name of a school/day care and address here.) 4 CONFIDENTIAL If NOT confidential, write name of school(s)/day care(s) and address(es) below: 5 (1) Name of school or day care____________________________________________ 6 Address______________________________________________________________ 7 City ________________________ County ____________________ State _________ 8 9 (2) Name of school or day care____________________________________________ 10 Address______________________________________________________________ City ________________________ County ____________________ State _________ 11 12 (3) Name of school or day care____________________________________________ 13 Address______________________________________________________________ 14 City ________________________ County ____________________ State _________ 15 16 17 (H) Order the Adverse Party to stay at least 100 yards away from my place(s) of employment. (I) Order the Adverse Party to stay at least 100 yards away from the following places, 18 which I or the minor child(ren) frequent regularly: 19 (1) Name _____________________________________________________________ 20 Address______________________________________________________________ 21 City ________________________ County ____________________ State _________ 22 23 (2) Name ____________________________________________________________ Address______________________________________________________________ 24 City ________________________ County ____________________ State _________ 25 26 (3) Name_____________________________________________________________ 27 Address______________________________________________________________ 28 City ________________________ County ____________________ State _________ 7 American LegalNet, Inc. www.FormsWorkflow.com 1 (J) (1) Prohibit the Adverse Party, either directly or through an agent, from physically 2 injuring or threatening to injure any animal that is owned or kept by the Adverse Party, the 3 minor child(ren), or me. 4 (2) Prohibit the Adverse Party, either directly or through an agent, from taking 5 possession of any animal owned or kept by me or the minor child(ren). 6 (K) I further request the following other conditions: 7 ___________________________________________________________________________ 8 ___________________________________________________________________________ 9 ___________________________________________________________________________ 10 ___________________________________________________________________________ 11 __________________________________________________________________________ 12 __________________________________________________________________________ 13 _________________________________________________________________________. 14 IF YOU WISH TO APPLY FOR A HEARING FOR AN EXTENDED ORDER FOR PROTECTION COMPLETE THE FOLLOWING INFORMATION 15 16 17 18 19 14. I request the Court hold a hearing for an EXTENDED ORDER FOR PROTECTION AGAINST DOMESTIC VIOLENCE (which could be in effect for up to one year), and at that hearing the Court issue an Extended Order for Protection Against Domestic Violence and that it include the following relief and any other relief the Court deems appropriate. 20 (Please check all the choice(s) that may apply to YOU). 21 (A) Prohibit the Adverse Party, either directly or through an agent, from threatening, 22 physically injuring, or harassing me and/or the minor child(ren). 23 (B) Prohibit the Adverse Party from any contact with me whatsoever. 24 (C) Exclude the Adverse Party from my residence and order the Adverse Party to stay at 25 least 100 yards away from my residence. (D) Grant temporary custody of the minor child(ren) to me. 26 (E) Grant the Adverse Party visitation with the minor child(ren). 27 (F) Order the Adverse Party to pay support and maintenance of the minor child(ren). (You 28 may be required to file an Affidavit of Financial Condition prior to the hearing). 8 American LegalNet, Inc. www.FormsWorkflow.com 1 (G) Order the Adverse Party to pay the rent or make payments on a mortgage or pay 2 towards my support and maintenance. 3 (H) Order that custody, visitation, and support of the minor child(ren) remain as ordered in 4 the Decree of Divorce/Order entered in Case Number ____________in the __________________________________ Court of the State of ___________. 5 (I) Order the Adverse Party to stay at least 100 yards away from the minor child(ren)’s 6 school, or day care, located at: 7 (If confidential, do not write name of school and address here). 8 9 CONFIDENTIAL If address is not confidential, please write name of school or day care and address(es) below: 10 (1) Name of school or day care_________________________________________ 11 Address: __________________________________________________________ 12 City ____________________________ County _________________State _____ 13 14 (2) Name of school or day care_________________________________________ 15 Address___________________________________________________________ 16 City ____________________________County _________________State______ 17 3) Name of school or day care_________________________________________ 18 19 Address___________________________________________________________ City ____________________________County _________________ State _____ 20 21 (J) Order the Adverse Party to stay at least 100 yards away from my place of 22 employment. 23 CONFIDENTIAL If address is not confidential, please write name of employer and address(es) below: 24 (1) Name of Employer__________________________________________________ 25 Address: _____________________________________________________________ 26 City ____________________________ County _______________State___________ 27 28 9 American LegalNet, Inc. www.FormsWorkflow.com 1 (2) Name of Employer__________________________________________________ 2 Address______________________________________________________________ 3 City ____________________________County ________________State__________ 4 (3) Name of Employer__________________________________________________ 5 Address______________________________________________________________ 6 City _____________________________County _______________State _________ 7 8 (K) Order the Adverse Party to stay at least 100 yards away from the following places, 9 which I or the minor child(ren) frequent regularly: 10 (1) Name __________________________________________________________ 11 Address: __________________________________________________________ 12 City __________________________County _______________State__________ 13 14 (2) Name __________________________________________________________ 15 Address___________________________________________________________ 16 City __________________________County _______________State __________ 17 (3) Name___________________________________________________________ 18 19 Address___________________________________________________________ City __________________________County _____________State ____________ 20 21 (L) (1) Prohibit the Adverse Party, either directly or through an agent, from physically 22 injuring or threatening to injure any animal that is owned or kept by the Adverse Party, 23 the minor child(ren), or me. 24 (2) 25 possession of any animal owned or kept by me or the minor child(ren). 26 (3) 27 animal owned or kept by the Adverse Party, the minor child(ren), or me. Prohibit the Adverse Party, either directly or through an agent, from taking I request the Court to specify the arrangements for the possession and care of any 28 10 American LegalNet, Inc. www.FormsWorkflow.com 1 (M) Order the Adverse Party to pay for lost earnings and expenses incurred as a result of 2 my attendance at any hearing concerning this Application. 3 (N) I further request the following other conditions: 4 ____________________________________________________________________________________ 5 ____________________________________________________________________________________ 6 ____________________________________________________________________________________ 7 ____________________________________________________________________________________ 8 ____________________________________________________________________________________ 9 ____________________________________________________________________________________ 10 ____________________________________________________________________________________ 11 ____________________________________________________________________________________ 12 ____________________________________________________________________________________ 13 ____________________________________________________________________________________. 14 15 16 17 I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF NEVADA THAT I HAVE READ THE STATEMENTS CONTAINED IN THIS APPLICATION, KNOW THE CONTENTS THEREOF, AND BELIEVE THEM TO BE TRUE AND CORRECT 18 Dated: _____________ 19 20 _________________________________________ Signature of Applicant 21 22 _________________________________________ Applicant’s Name (Please Print) 23 24 25 26 27 28 11 American LegalNet, Inc. www.FormsWorkflow.com