Nebraska State Court Form REQUIRED REQUEST FOR MODIFICATION TO DOMESTIC ABUSE PROTECTION ORDER DC 19:19 Rev. 1/17 Neb. Rev. Stat. 247 42-924 Page 1 of 2 Request for Modification to Domestic Abuse Protection Order DC 19:19 Rev 1/17 IN THE DISTRICT COURT OF COUNTY, NEBRASKA Petitioner, Additional Petitioner/Minor Child(ren), Additional Petitioner/Minor Child(ren), vs. Case No. REQUEST FOR MODIFICATION TO DOMESTIC ABUSE PROTECTION ORDER Respondent. I, , am the petitioner in this case. I am requesting a modification to the existing domestic abuse protection order issued on pursuant to Neb. Rev. Stat. 247 42-924. This request will apply to the following protected party(ies): 1.age: 2.age: 3.age: 4.age: 5.age: 6.age: 1.The modification(s) requested is/are detailed below: 2.Reason(s) for modification are stated below: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Request for Modification to Domestic Abuse Protection Order DC 19:19 Rev 1/17 NOTE: DO NOT SIGN UNTIL THE CLERK OF THE DISTRICT COURT OR A NOTARY IS PRESENT AND WITNESSES YOU SIGNING I hereby swear, or affirm, under penalty of perjury, the forgoing is true. *If you are concealing your address or phone, do not provide them. Make separate arrangements with the clerk. Date Signature of Petitioner Name*Street Address/P.O. Box Bar Number and Firm Name (attorneys only) City/State/ZIP Code Phone E-mail Address Subscribed and sworn before me on , 20 Clerk of the Court/Notary Public (Seal) My Commission Expires: American LegalNet, Inc. www.FormsWorkFlow.com