JUSTICE COURT, LAS VEGAS TOWNSHIP COUNTY OF CLARK, STATE OF NEVADA APPLICANT CONFIDENTIAL INFORMATION WORKSHEET HARM TO MINORS Applicant’s Full Name: ____________________________________________________________ AKA: ________________________________________________________ Date of Birth: ______________________ Sex: M ____ F ____ Race: ____________________ Address: ________________________________________________________________________ City: __________________________ State: _______________________ Zip: ___________ Home Phone: ______________________ Cell (alternate) Phone: _____________________ Additional contact person (name/phone): ________________________________________________ What is the relationship (if any) between the Applicant and the Adverse party? _______________________________________________________________________________ Are you (applicant) the custodial parent of the victim? YES ____ NO ____ Are there, or have there been in the past, any court actions between the Applicant and the Adverse party? YES ___ NO ___ If yes, please explain: _____________________________________________________________________________________ _____________________________________________________________________________________ Does the Applicant have any restrictions on contact with the minor victim through a divorce decree or paternity action (i.e. supervised or limited visitation)? YES ___ NO ___ If yes, please explain: _____________________________________________________________________________________ _____________________________________________________________________________________ COURT PERSONNEL ONLY: Identification Verified [ ] _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ CONFIDENTIAL American LegalNet, Inc. www.USCourtForms.com