1 APPO 2 DISTRICT COURT, 3 FAMILY DIVISION, 4 CLARK COUNTY, NEVADA 5 , 6 Applicant, Case No. T vs. 7 8 , Adverse Party. 9 APPLICATION FOR A TEMPORARY AND/OR EXTENDED ORDER FOR PROTECTION 10 AGAINST DOMESTIC VIOLENCE 11 Applicant states the following facts under penalty of perjury: 12 Applicant Date of Birth: Adverse Party Date of Birth: 1. My relationship to the Adverse Party is (for example, current/former husband, current/former wife, 13 current/former boyfriend, current/former girlfriend, father, mother ,brother, sister, etc.): 14 . Length of relationship: .15 Have you ever lived together? Yes or No . If so, how long? .16 Are you living together now? Yes or No . 17 Date of Separation: . We have child(ren) TOTOTOTOGGGGEEEETHERTHERTHERTHER:::: Yes or No . If yes, where and with whom are these18 child(ren) living? .19 2. My address is: CONFIDENTIAL , (If confidential do not write address here) 20 or, if not confidential list City___________________________________ County State Zip Code 21 Phone . 22 I own rent this residence. Lease/title is held in all the following name(s): 23 I have been living in this residence for .24 3. Adverse Partys address is: 25 City County State Zip Code 26 Phone:______________________________ . 27 Adverse Party has been living in this residence for .28 - 1 - >>>> 2 1 4. My employment is: CONFIDENTIAL , (If confidential do not write address here) 2 or, if not confidential, state place of employment Address: 3 City County State Zip Code 4 Phone _______________________ 5. Adverse Partys employment is: 5 Address: 6 City County State Zip Code 7 Phone 6. (a) The name(s) and dates of birth of minor child(ren) who I am the parent of, or who live in my 8 home, are as follows: 9 NAME(first and last) Date of APPLICANTS CHILD ADVERSE PARTYS WHO CHILD10 Birth (YES/NO) CHILD (YES/NO) LIVES WITH 1. Check one Check one 11 Yes No Yes No 12 2. Check one Check one Yes No Yes No 13 3. Check one Check one Yes No Yes No 14 4. Check one Check one 15 Yes No Yes No 16 5. Check one Check one Yes No Yes No 17 (b) Have you or the Adverse Party ever been awarded custody of the minor child(ren) that you have in 18 common by Court order? Yes No 19 Who was awarded custody? Applicant Adverse Party 20 By what Court? Case No. 21 22 23 24 25 26 27 28 - 2 - >>>> 3 1 7. Please check the appropriate box, IF YOU or the ADVERSE PARTY has ever filed a case in any Court for 2 Divorce, Custody, Paternity, Child Support, Guardianship, Order for Protection, 3 Stalking/Harassment Order. Please indicate when and where the case was filed, and list the case numbers. 4 5 6 7 8. Has CHILD PROTECTIVE SERVICES (CPS) ever been contacted regarding any member of the household 8 in the past year? Yes No. Is CPS currently involved with this family? Yes No. 9 If yes to the question, give details, including the caseworkers name: 10 11 12 13 14 9. I have been or reasonably believe I will become a victim of domestic violence committed by the15 Adverse Party. 16 My child(ren) have been or are in danger of being a victim of domestic violence committed by the17 Adverse Party. 18 19 20 21 22 23 24 25 26 27 28 - 3 - >>>> 4 1 InInInIn the thethethe followin followinfollowinfollowingggg sp spspspace,ace,ace,ace, state statestatestate the thethethe fa fafafaccccttttssss which whichwhichwhich s sssuuuupporpporpporpportttt you youyouyourrrr a aaapplicpplicpplicpplicaaaattttionionionion.... 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To your knowledge, has the ADADADADVEVEVEVERSRSRSRSEEEE PART PARTPARTPARTYYYY ever been arrested or charged with domestic violence, or any other crime committed against his/her spouse, partner, or child(ren)? Yes No. If yes, WHEN 5 and where? 6 7 8 12. An emergency exists, and I need a TEMPORARY ORDER FOR PROTECTION AGAINST DOMESTIC 9 VIOLENCE issued immediately without notice to the Adverse Party to avoid irreparable injury or 10 harm. I request that it include the following relief (please check all the choices that apply to you): (a) Prohibit the Adverse Party, either directly or through an agent, from threatening, 11 physically injuring or harassing me and/or my minor child(ren). 12 (b) Prohibit the Adverse Party from any contact with me whatsoever. (c) Exclude the Adverse Party from my residence and order the Adverse Party to stay at 13 14 least 100 yards away from my residence. (d) Obtain law enforcement assistance to accompany me to the following residence, 15 , or to accompany the Adverse Party,16 to the following residence, to obtain personal property. 17 (e) Grant temporary custody of the minor child(ren) to me. 18 (f) Order that custody, visitation, and support of the minor child(ren) remain as ordered in the Decree of Divorce/Order entered in Case Number in the 19 20 Judicial District Court of the State of . (g) Order the Adverse Party to stay at least 100 yards away from the minor child(ren)s 21 school, or day care, located at CONFIDENTIAL , (If confidential do not write address22 here) or, if not confidential list 1. Address: ________________________________________________________________________________________________ 23 City County State Zip Code 24 2. Address: 25 City County State