STATE OF NEBRASKA FORM NO. DC 19-5 Copy DC 19:3 on reverse of form. Rev. 6/08; Neb. Rev. Stat. § 28311.09 CASE NUMBER: HARASSMENT PROTECTION ORDER IN THE DISTRICT COURT OF DOCUMENT No.: COUNTY, NEBRASKA HARASSMENT PROTECTION ORDER Petitioner (After hearing, Ex Parte order issued) vs. Respondent THIS MATTER came on before the Court, pursuant to Neb. Rev. Stat. § 28-311.09, upon the petition of the petitioner. The petitioner ( was) ( was not) present in court ( ). The respondent ( did) ( with counsel, did not) appear ( with counsel, ). Evidence was adduced, and the Court, being fully advised, finds that this court has jurisdiction of the parties and subject matter of this action. IT IS THEREFORE ORDERED that unless modified by the court, the harassment protection , order issued on , shall remain in effect for a period of one year from the date of the original order. IT IS FURTHER ORDERED that all costs of filing and service in this case are ( taxed to the petitioner as the court finds, by clear and convincing evidence, that the statements contained in the petition were false and the harassment protection order was sought in bad faith) or ( ( waived). DATED on: taxed to the respondent) or , JUDGE NOTICE TO RESPONDENT PURSUANT to the Violence Against Women Act of 1994, this order is enforced in all fifty states, the District of Columbia, tribal lands and U.S. territories. Moreover, if this order was entered after a hearing of which you had actual knowledge and an opportunity to participate, whether or not you actually participated and if this court order restrains you from harassing, stalking, or threatening an intimate partner or child of such intimate partner, or engaging in other conduct that would place an intimate partner in reasonable fear of bodily injury to the partner or child, you may be subject to a federal penalty for possessing, transporting, or accepting a firearm or ammunition under the 1994 amendment to the Gun Control Act. American LegalNet, Inc. www.FormsWorkflow.com