STATE OF NEBRASKA FORM NO. DC 19:10 Copy DC 19:9 on reverse of form Rev. 10/08 Neb. Rev. Stat.42-924 EX PARTE DOMESTIC ABUSE PROTECTION ORDER CASE NUMBER: DOCUMENT NO.: COUNTY, NEBRASKA IN THE DISTRICT COURT OF EX PARTE DOMESTIC ABUSE PROTECTION ORDER Petitioner vs. Respondent And/or on behalf of minor family member(s): NAME AGE The Petitioner alleges as follows: The Petitioner’s Relationship to the respondent is: □ Spouse □ Former spouse □ A person he/she is currently living with □ A person he/she has lived with in the past □ Child in common □ Related by blood or marriage □ Child(ren) (The following do not qualify for 18 U.S.C 922(g)(8)) □ A person he/she is presently involved with in a dating relationship □ A person he/she was involved with in a dating relationship ________________________________________________________ Respondent’s Address ________________________________________________________ ________________________________________________________ Respondent’s Telephone Number RESPONDENT IDENTIFIERS SEX RACE EYES AGE HAIR DRIVERS LICENSE # HT WT DISTINGUISHING FEATURES STATE EXP DATE Additional distinguishing features: ______________________________________________ ______________________________________________ CAUTION: (for use by law enforcement) Weapon Involved Weapon Present on the Property The terms of this order shall be effective until one year from the date of issuance, unless vacated by the court prior to such date. WARNINGS TO RESPONDENT: This order shall be enforced, even without registration, by the courts of any state, the District of Columbia, any U.S. Territory, and may be enforced by Tribal Lands (18 U.S.C. Section 2265). Crossing state, territorial, or tribal boundaries to violate this order may result in federal imprisonment (18 U.S.C. Section 2262). Federal law provides penalties for possessing, transporting, shipping, or receiving any firearm or ammunition (18 U.S.C. Section 922(g)(8)). Only the Court can change this order. 1 American LegalNet, Inc. www.FormsWorkflow.com THE COURT, hereby finds that it has jurisdiction over the parties and subject matter, and the Respondent has been or will be provided with reasonable notice and opportunity to be heard. THE COURT, pursuant to Neb. Rev. Stat. §§ 42-924 and 42-925, upon ex parte consideration of the Petition and Affidavit, finds that the petitioner has stated facts showing that the respondent (1) attempted to cause, or intentionally, knowingly, or recklessly caused, bodily injury to the petitioner, or (2) by physical menace, placed the petitioner in fear of imminent bodily injury. FURTHER, it reasonably appears from the specific facts included in the affidavit that the petitioner will be in immediate danger of abuse before the If checked, the court finds that such facts show that the respondent represents a matter can be heard on notice. credible threat to the physical safety of the petitioner (18 USC § 922(g)(8)). IT IS THEREFORE ORDERED that, unless modified by order of the court, a domestic abuse protection order against the respondent is granted for a period of one year from the date of this order and the petitioner is granted the following relief: 1. 2. 3. 4. Respondent is enjoined from imposing any restraint upon the person or liberty of the petitioner. Respondent is enjoined from threatening, assaulting, molesting, attacking, or otherwise disturbing the peace of the petitioner. Respondent is enjoined from telephoning, contacting, or otherwise communicating with the petitioner, except Respondent is removed and excluded from the residence of the petitioner, regardless of the ownership of the residence, located at: 5. The respondent is ordered to stay away from the following location(s): 6. The petitioner is awarded temporary custody of the following minor children, such temporary , custody shall remain in effect until: 7. Notice is hereby given to the petitioner and respondent that a hearing has been set for: _________________________________. The hearing will be held at the following location: ______________________________________________. If the respondent wishes to appear and show cause why this order should not remain in effect for a period of one year, he or she shall appear at the above scheduled hearing. IT IS FURTHER ORDERED that a copy of this order and a copy of the petition be served on the respondent and a copy of this order be mailed to the petitioner. DATED on , JUDGE 2 American LegalNet, Inc. www.FormsWorkflow.com