Nebraska State Court Form REQUIRED PETITION AND AFFIDAVIT TO OBTAIN HARASSMENT PROTECTION ORDER DC 19:2 Rev. /17 Neb. Rev. Stat. 247 28-311.09 Page 1 of 4 Petition and Affidavit to Obtain Harassment Protection Order DC 19:2 Rev. /17 IN THE DISTRICT COURT OF COUNTY, NEBRASKA Petitioner, Case No. Additional Petitioner/Minor Child(ren), PETITION AND AFFIDAVIT TO OBTAIN HARASSMENT PROTECTION vs. Additional Petitioner/Minor Child(ren), ORDER Respondent. 1.I, , am the petitioner in this case. I am petitioning for a harassment protection order pursuant to Neb. Rev. Stat. 247 28-311.09. I am filing this petition on behalf of: Myself. I have been harassed. Myself and additional petitioner(s) who have been harassed and whose name(s) is/are shown after mine in the caption of this petition. My relationship to the additional petitioner(s)/minor child(ren) is/are: custodial parent, guardian, other: . Only on behalf of the additional petitioner(s) who have been harassed and whose name(s) is/are shown after mine in the caption of this petition. My relationship to the additional petitioner(s)/minor child(ren) is/are: custodial parent, guardian, other: . AND: I am a minor and years of age. I am 19 or older or legally emancipated OR I do not speak English. The language that I speak is: . 2.Check Only One: I have received address protection from the Secretary of State under the Address Confidentiality Program.(Service of any court process shall be made by mailing two copies of the process to the Office of Secretary of State, Address Confidentiality Program, Suite 2300, State Capitol Building, Lincoln, NE, 68509) I am living at a safe house or shelter for my own protection. Pursuant to Neb. Rev. Stat. 24729-4303, I cannot identify the name, address, location or phone number of the facility. My address is: (Street or Route/Box) Mailing address (if different): (City) (State) (ZIP code) (Street or Route/Box) (City) (State) (ZIP code) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4 Petition and Affidavit to Obtain Harassment Protection Order DC 19:2 Rev. /17 3. I do not agree to receive notification by e-mail. I agree to receive notification by e-mail. e-mail address: NOTE: By providing this e-mail address, I acknowledge that I am aware that this information will be public record. I also understand that I will only receive e-mail communications regarding this case from the court. 4.I am filing this petition against the respondent whose age is:and who resides at: (Street or Route/Box) Mailing address (if different) (City) (State) (ZIP code) (Street or Route/Box) (City) (State) (ZIP code) (Phone number) The respondent does not speak English. The language that the respondent speaks is: My relationship to the respondent is: . 5.The respondent is a person who has willfully harassed me and has engaged in a knowing and willfulcourse of conduct directed at me which seriously terrifies, threatens, or intimidates me and serves nolegitimate purpose. 6.To my knowledge, The respondent and I have or have not been involved in past or current court cases together. (i.e., divorce, paternity, custody, juvenile, criminal or protection orders) If so: when, where,type of case, name of court(s), and case number(s). 7.I hereby ask the court to enter a protection order (mark all that apply):prohibiting the respondent from imposing any restraint upon the person(s) seeking protection. prohibiting the respondent from harassing, threatening, assaulting, molesting, attacking, or otherwise disturbing the peace of the person(s) seeking protection. prohibiting the respondent from telephoning, contacting, or otherwise communicating with the person(s) seeking protection. 8.Pursuant to Neb. Rev. Stat. 247 25-2740, I request to have a District Court Judge, or a County Court Judge preside over this proceeding.(I understand this request may not be granted.). 9.The facts of the most recent series of acts of harassment toward the person(s) seeking protection are (Pleasewrite a brief but detailed description.): A. Date/Time: Description: . American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4 Petition and Affidavit to Obtain Harassment Protection Order DC 19:2 Rev. 1/17 Relationship to the Respondent: B. Date/Time: Description: C. Date/Time: Description: 10.Additional Petitioner(s) (if needed): Petitioner 2 (Minor Child): Name:Age: Residence: The address of this Petitioner is the same as my address above. This Petitioner222s address is: (Street or Route/Box) (City) (State) (Z) Petitioner 3 (Minor Child): Name: Age: Residence: The address of this Petitioner is the same as my address above. This Petitioner222s address is: (Street or Route/Box) (City) (State) (Z Relationship to the Respondent: American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 4 Petition and Affidavit to Obtain Harassment Protection Order DC 19:2 Rev. 1/17 Petitioner 4 (Minor Child): Name: Age: Residence: The address of this Petitioner is the same as my address above. This Petitioner222s address is: (Street or Route/Box) (City) (State) (Zip) Petitioner 5 (Minor Child): Name: Age: Residence: The address of this Petitioner is the same as my address above. This Petitioner222s address is: (Street or Route/Box) (City) (State) (Zip) Petitioner 6 (Minor Child): Name: Age: Residence: The address of this Petitioner is the same as my address above. This Petitioner222s address is: (Street or Route/Box) (City) (State) (Zip) I hereby swear, or affirm, under penalty of perjury, the foregoing affidavit is true. Signature of Petitioner (Firm name and Bar Number IF being completed by an attorney) (do NOT sign UNTIL THE CLERK OF THE DISTRICT COURT OR A NOTARY IS PRESENT AND WITNESSES YOU SIGNING) Subscribed and sworn before me on , 20 Clerk of the Court/Notary Public (Seal) My Commission Expires: Relationship to the Respondent: Relationship to the Respondent: Relationship to the Respondent: American LegalNet, Inc. www.FormsWorkFlow.com