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Application For A Temporary And Or Extended Order For Protection Against Domestic Violence Form. This is a Nevada form and can be use in Washoe County.
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Tags: Application For A Temporary And Or Extended Order For Protection Against Domestic Violence, Nevada County, Washoe
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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:
Index No.
:
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CODE 1255
Plaintiff(s)
2
-against-
Calendar No.
:
JUDICIAL SUBPOENA
:
3
:
4
:
5
6
Defendant(s)
:
......................................................
IN THE FAMILY DIVISION
OF THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA,
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8
IN AND FOR THE COUNTY OF WASHOE
THE PEOPLE OF THE STATE OF NEW YORK
9
TO
,
10
Applicant,
11
GREETINGS:
12
vs.
Case No.
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
Dept.CourtDM
No.
,
the Honorable
at the
located at
County of
,
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
Adverse Party.
or adjourned date, to testify and give evidence as a witness in this action on the part of the
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14
15
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APPLICATION FOR A TEMPORARY AND/OR EXTENDED ORDER FOR PROTECTION AGAINST
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
DOMESTIC VIOLENCE
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result ofApplicant states the following facts under penalty of perjury:
your failure to comply.
18
19
20
Applicant Date of Birth: _____________ Adverse Party Date ofJustices of the
Witness, Honorable
, one of the Birth:___________
Court in
County,
day of
, 20
1.
My relationship to the Adverse Party is (for example, current/former husband, current/former wife,
21
current/former boyfriend, current/former girlfriend, father, mother, brother, sister, etc.):
22
_
23
Ë
Attorney(s) for
Length of relationship: ____________________ .
24
Ë
Have you ever lived together?
25
Ë
Are you living together now? Yes or No Office and P.O. Address
__________.
Ë
Date of Separation: _______________________.
Telephone No.:
We have child(ren) TOGETHER: Yes or No _______________. If yes, where and with
Facsimile No.:
E-Mail Address:
.
whom are these child(ren) living?
Mobile Tel. No.:
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27
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(Attorney must sign above and type name below)
Ë
__________.
Yes or No __________. If so, how long? __________.
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Index No.
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2.
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I
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Calendar No.
CONFIDENTIAL , (If confidential do not write address here)
:
JUDICIAL SUBPOENA
Plaintiff(s)
or, if not confidential list
-against:
City
State
Zip Code
Phone
My address is:
own
rent this residence. Lease/title is held :in all the following name(s):
:
I have been living in this residence for
Defendant(s)
:
......................................................
3.
Adverse Party’s address is:
7
City
State
Zip Code
8
THE PEOPLE OFParty STATE OF living YORK residence for
Adverse THE has been NEW in this
9
4.
TO
Phone
My employment is:
CONFIDENTIAL, (If confidential do not write address here)
or, if not confidential, state place of employment
10
Address:
Phone:
11
GREETINGS:
City
12
5.
Adverse Party’s employment business and excuses being laid aside, you and each of you attend before
WE COMMAND YOU, that all is:
,
the Honorable
at the
Court
Address:
Phone
located at
County of
in room City
, on the
day of County , 20
, at
o'clock in the
noon, and at any recessed
State
or adjourned date, to testify and give evidence as a witness in this action on the part of the
6.
(a)
The name(s) and dates of birth of minor child(ren) who I am the parent of, or who live
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15
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County
State
in my home, are as follows.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
NAME (first and last)
Date of
APPLICANT’S CHILD
ADVERSE PARTY’S
WHO CHILD
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damagesLIVES WITH a
sustained as
Birth
CHILD (YES/NO)
(YES/NO)
result of your failure to comply.
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Circle one
Yes
No
No
, one Yesthe Justices of the
of
20
2.
, 20
Circle one
Yes
No
Circle one
Yes
21
3.
Circle one
Circle one
Yes (Attorney must sign above and type No below)
No
Yes
name
4.
Circle one
Yes
1.
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22
Witness, Honorable
Court in
County,
day of
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24
Circle one
Yes
5.
25
(b)
26
you have in common by Court order?
27
Who was awarded custody?
28
Circle one
No
Circle one
Yes
No
No
Attorney(s) for
No
Circle one
Yes
No
Have you or the Adverse Party ever been Office andcustody of the minor child(ren) that
awarded P.O. Address
Yes
Applicant
By what Court?
-2-
No
Adverse Party
Telephone No.:
Facsimile No.: Case No.
E-Mail Address:
Mobile Tel. No.:
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Index No.
Calendar No.
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2
7.
3
4
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6
:
JUDICIAL SUBPOENA
Plaintiff(s)
Please check the appropriate box, IF YOU or the ADVERSE PARTY has ever filed a case in any
-against:
Custody,
Paternity,
Child Support,
Guardianship, Order
Court for a Divorce,
:
for Protection,
Stalking/Harassment Order. Please indicate when and where the case was
:
filed, and list the case numbers. Defendant(s)
:
......................................................
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8
8.
Has CHILD PROTECTIVE SERVICES (CPS) ever been contacted regarding any member of the
THE PEOPLE OF THE STATE OF NEW YORK
9
TO
10
household in the past five year?
Yes
No. Is CPS currently involved with this family?
Yes
No.
11
If yes
GREETINGS: to the question, give details, including the caseworker’s name:
12
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
9.
I have been or evidence as witness I will become part of the
or adjourned date, to testify and give reasonablya believe in this action on thea victim of domestic violence
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committed by the Adverse Party.
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
My child(ren) have was or are a danger penalty of victim of domestic violence
the party on whose behalf this subpoenabeen issued forin maximumof being a$50 and all damages sustained as a
result of your failure to comply.
committed by the Adverse Party.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
20
21
(Attorney must sign above and type name below)
22
Attorney(s) for
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25
Office and P.O. Address
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27
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
28
-3-
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Index No.
:
Calendar No.
In the following space, state the facts which support your application. Be as specific as you can,
:
starting with the most recent incident. Include the approximateJUDICIALlong it has gone on, and
dates, how SUBPOENA
Plaintiff(s)
whether law enforcement or medical personnel have been involved.
-against:
3
:
4
:
5
6
Defendant(s)
:
......................................................
7
8
THE PEOPLE OF THE STATE OF NEW YORK
9
TO
10
11
GREETINGS:
12
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
13
14
15
16
17
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
18
19
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
20
21
(Attorney must sign above and type name below)
22
Attorney(s) for
23
24
25
Office and P.O. Address
26
27
28
Please do not write on the backs of
Telephone No.:
Facsimile No.:
any E-Mail Address:
pages.
Mobile Tel. No.:
-4-
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10.
2
3
:
Calendar No.
Have YOU ever been arrested or charged with domestic violence, or any other crime
:
JUDICIAL SUBPOENA
Plaintiff(s)
committed against your spouse, partner, or child(ren)? G Yes G No. If yes, WHEN and
-against:
where?
:
4
5
6
Index No.
:
11.
To your knowledge, has the ADVERSE PARTY ever been arrested or charged with domestic
Defendant(s)
:
......................................................
violence, or any other crime committed against his/her spouse, partner, or child(ren)? G Yes
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8
G No. If yes, WHEN and where?
THE PEOPLE OF THE STATE OF NEW YORK
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TO
10
12.
11
DOMESTIC VIOLENCE issued immediately without notice to the Adverse Party to avoid
GREETINGS:
12
irreparable injury or harm. I request that it include laid aside, you relief (please check before
WE COMMAND YOU, that all business and excuses being the following and each of you attendall the
,
the Honorable
at the
Court
located at
County of choice(s) that apply to you):
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjournedG (a) testify and give evidenceParty, either directly or on the part of agent, from threatening,
date, to Prohibit the Adverse as a witness in this action through an the
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G An emergency exists, and I need a TEMPORARY ORDER FOR PROTECTION AGAINST
physically injuring or harassing me and/or my minor child(ren).
G (b) to comply with this subpoena from any contact with of whatsoever.
Your failureProhibit the Adverse Party is punishable as a contemptme court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply. Adverse Party from my residence and order the Adverse Party to stay
G (c) Exclude the
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19
20
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at least 100
Witness, Honorable yards away from my residence.
, one of the Justices of the
Court in
County,
day of
, 20
G (d) Obtain law enforcement assistance to G accompany me to the following
residence,
(Attorney must sign above and type name below)
, or G to accompany the
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24
Adverse Party, to the following residence,
Attorney(s) for
to obtain personal property.
25
G (e) Grant temporary custody of the minor child(ren) toAddress
Office and P.O. me.
26
G (f) Order that custody, visitation, and support of the minor child(ren) remain as ordered
27
28
Telephone No.:
in the Decree of Divorce/Order entered in Case Number
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
-5-
in the
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G
Index No.
:
Calendar No.
Court of the State of ___________________.
:
JUDICIAL SUBPOENA
Plaintiff(s)
(g) Order the Adverse Party to stay at least 100 yards away from the minor
-against:
3
4
child(ren)’s school, or day care, located at G CONFIDENTIAL, (If confidential do not
:
write address here) or, if not confidential list G
:
5
6
Address:
Defendant(s)
:
......................................................
City
County
State
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8
G (h) Order the Adverse Party to stay at least 100 yards away from my place of
THE PEOPLE OF THE STATE OF NEW YORK
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TO
10
employment.
G (I) Order the Adverse Party to stay at least 100 yards away from places which I or my
minor child(ren) frequent regularly: G CONFIDENTIAL, (If confidential do not write
11
GREETINGS:
12
address YOU, that all business and excuses being laid aside, you and each of you attend before
WE COMMAND here) or, if not confidential list G
,
the Honorable
at the
Court
Address:
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
County
State
or adjourned date,City
to testify and give evidence as a witness in this action on the part of the
13
14
15
16
17
G (j) I further request the following other conditions:
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
18
19
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
20
21
(Attorney must sign above and type name below)
22
Attorney(s) for
23
24
25
Office and P.O. Address
26
27
28
IF YOU WISH TO APPLY FOR A
Telephone No.:
Facsimile No.:
HEARING FOR AN
E-Mail Address:
Mobile Tel. No.:
-6-
EXTENDED ORDER
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:
Index No.
Calendar No.
FOR PROTECTION COMPLETE THE FOLLOWING INFORMATION
:
1
JUDICIAL SUBPOENA
Plaintiff(s)
2
-against-
:
3
4
13.
AGAINST DOMESTIC VIOLENCE (which could: be in effect for up to one year), and at
5
6
:
I request the Court hold a hearing for an EXTENDED ORDER FOR PROTECTION
Defendant(s)
:
. . . . . . . . . . .that .hearing. the .Court .issue. an .Extended. Order for Protection Against Domestic
... ...... ... ..... .... .. ........ .....
Violence and that it include the following relief (please check all the choice(s) that apply
7
8
THE PEOPLE OF THE STATE OF NEW YORK
to you):
9
TO
10
(a) Prohibit the Adverse Party, either directly or through an agent, from
threatening, physically injuring or harassing me and/or my minor child(ren).
11
GREETINGS:
12
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
(c) Exclude the Adverse Party from my residence and order the Adverse Party to
,
the Honorable
at the
Court
located at
County of
stay the least day of
100 yards away, from my residence. in the
in room
, on at
20
, at
o'clock
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
(d) Grant temporary custody of the minor child(ren) to me.
13
14
15
16
17
18
19
20
(b) Prohibit the Adverse Party from any contact with me whatsoever.
(e) Grant the Adverse Party visitation with the minor child(ren).
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a support and maintenance of the minor child(ren).a
(f) Order the Adverse Party to pay maximum penalty of $50 and all damages sustained as
result of your failure to comply.
(You may be required to file an affidavit of financial condition prior to the hearing.)
Witness, Honorable
, one of the Justices of the
Court in
day of
, 20
(g) County,
Order the Adverse Party to pay the rent or make payments on a mortgage or
pay towards my support and maintenance.
21
22
(Attorney must sign above and type name below)
(h) Order that custody, visitation, and support of the minor child(ren) remain as
23
ordered in the Decree of Divorce/Order entered in Case Number
Attorney(s) for
24
in the
Court of the State of ________________.
25
(i) Order the Adverse Party to stay at least 100 yards away from the minor
Office and P.O. Address
26
child(ren)’s school, or day care, located at:
27
Telephone
not write address here) or, if not confidential list No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
28
-7-
CONFIDENTIAL (If confidential do
,
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COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Address:
1
2
City
Plaintiff(s)
County
-against-
Calendar No.
:
JUDICIAL SUBPOENA
:
State
3
:
4
5
6
(j) Order the Adverse Party to stay at least 100 yards away from my place of
:
Defendant(s)
employment.
:
......................................................
(k) Order the Adverse Party to stay at least 100 yards away from places which I or
7
8
my minor child(ren) frequent
THE PEOPLE OF THE STATE OF NEW YORK regularly:
9
TO
CONFIDENTIAL (If confidential do not
,
write address here) or, if not confidential list
Address:
10
11
GREETINGS:
12
WE COMMAND YOU, that all business and excuses conditions:
(l) I further request the following other being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
13
14
City
County
State
15
16
17
18
19
20
21
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
I CERTIFY UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE
STATE OF NEVADA THAT I HAVE READ THE STATEMENTS CONTAINED IN
Witness, Honorable
, one of the Justices of the
THIS APPLICATION, KNOW THE CONTENTS THEREOF, AND BELIEVE THEM
Court in
County,
day of
, 20
TO BE TRUE AND CORRECT
(Attorney must sign above and type name below)
Dated:
Signature of Applicant
22
Attorney(s) for
23
24
25
Applicant’s Name (Please Print)
SUBSCRIBED and SWORN before me
this
day of
,
Office and P.O. Address
.
26
27
NOTARY PUBLIC/DEPUTY COURT CLERK
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
28
-8-
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