STATE OF NEBRASKA FORM NO. DC 19-4 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 Petitioner vs. DOCUMENT No.: COUNTY, NEBRASKA HARASSMENT PROTECTION ORDER (Ex Parte) Respondent THE COURT, having received the Petition and Affidavit of the petitioner, finds that a harassment protection order pursuant to Neb. Rev. Stat. § 28-311.09 should be issued. FURTHER, it reasonably appears from the specific facts included in the affidavit that irreparable harm, loss or damage will result before this matter can be heard on notice, therefore, the court having jurisdiction of the parties finds that a harassment protection order should be issued. IT IS THEREFORE ORDERED, that unless modified by order of the court, pursuant to Neb. Rev. Stat. § 28-311.09 , a harassment 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 harassing, threatening, assaulting, molesting, attacking, or otherwise disturbing the peace of the petitioner. respondent is enjoined from telephoning, contacting, or otherwise communicating with the petitioner. this order shall also apply to the following family or household members: 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 affix his or her current address, telephone number, and signature on the Request for Hearing form provided and return it to the clerk of the district court within five (5) days after service upon him or her. This order shall remain in effect during the time prior to the hearing. Costs are waived unless otherwise ordered by the court. DATED on: , 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 no hearing is requested or a final order is entered against you 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