STATE OF NEBRASKA FORM NO. DC19:11B Copy DC19:9 on reverse of form Rev.10/08 Neb. Rev. Stat.42-924 MODIFIED DOMESTIC ABUSE PROTECTION ORDER CASE NUMBER: DOCUMENT NO.: COUNTY, NEBRASKA IN THE DISTRICT COURT OF MODIFIED 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 of the of the originating order (see page 2), 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 THIS MATTER came on before the Court, pursuant to Neb. Rev. Stat.§§ 42-924 and 42-925, upon ). the petition. The petitioner ( was) ( was not) present in court ( with counsel, ). Evidence was The respondent ( did) ( did not) appear ( with counsel, adduced, and the Court, being fully advised, finds that this court has jurisdiction of the parties and subject matter of this action, and that the petitioner has shown 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. If checked, the court finds that such facts show that the respondent represents a credible threat to the physical safety of the petitioner (18 USC § 922(g)(8)). IT IS THEREFORE ORDERED that, unless later further modified by the court, the domestic , shall remain in abuse protection order issued on effect for a period of one year from the date of the original order, as modified and restated in the following manner: 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. IT IS FURTHER ORDERED that all costs of filing and service in this case are ( respondent) or, ( waived). DATED on: taxed to the , JUDGE 2 American LegalNet, Inc. www.FormsWorkflow.com