1 2 3 4 Code: $3645 Name:______________________________ Address:____________________________ ___________________________________ Telephone:__________________________ Acting In Proper Person 5 6 IN THE FAMILY DIVISION 7 8 OF THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA 9 IN AND FOR THE COUNTY OF WASHOE 10 11 ________________________________, Petitioner, 12 13 14 15 16 vs Case No. _____________________ __________________________________, Respondent. ____________________________________/ Dept. No._________________ PETITION TO ESTABLISH CUSTODY AND VISITATION 17 18 Petitioner, ______________________________, acting in proper person, petitions this (Your name) 19 20 21 22 Court for an Order judicially establishing custody and visitation for the following minor children Child's Name Child's Birthdate ______________ _____________________________ ______________ _____________________________ 23 _____________________________ ______________ _____________________________ ______________ 24 25 26 27 Petitioner, _______________________________states as follows: 28 1 American LegalNet, Inc. www.FormsWorkflow.com 1 2 I. My present address is: 3 ______________________________________ 4 5 ______________________________________ 6 I have lived at that address for:__________________(circle one) days, months, years. 7 Prior to living at my present address, I lived at: 8 ______________________________________ 9 ______________________________________ 10 11 I lived at that address for ______________(circle one) days, months, years. II. 12 13 The child(ren) presently live at: 14 ______________________________________ 15 16 ______________________________________ 17 The child(ren) have lived at that address for _______________ (circle one) days, months, years. 18 The child(ren) are presently living with __________________________________________. (State with whom the children are presently living) 19 20 21 22 Prior to the present address the child(ren) lived at: _______________________________________ _______________________________________ 23 And the child(ren) lived at that address for ___________ (circle one) days, months, years. 24 25 The child(ren) lived at the prior address with ________________________________________. (State with whom the children lived at that address) 26 III. 27 28 The other parent of the child(ren) is:____________________________________________ (Name of the other parent) 2 American LegalNet, Inc. www.FormsWorkflow.com 1 That parent resides at: 2 ___________________________________ 3 ___________________________________ 4 5 The other parent has lives at that address for ___________(circle one) days, months, years. 6 Prior to living at that present address, the other parent lived at: 7 ___________________________________ 8 ____________________________________ 9 The other parent lived at that address for _____________(circle one) days, months, years. 10 IV. 11 12 13 Print "YES" on the line in front of the statement that fits your circumstances. Print "NO" on those lines that are not applicable to your set of circumstances. 14 15 The paternity of the child(ren) has been established by: 16 __________ 17 18 19 20 21 A voluntary acknowledgment of paternity was signed by both parents at the time of the child's birth and Father's name is on the birth certificate. __________ Paternity was established through a court proceeding in: Name of court:________________________________________ Address of court:_______________________________________ Date proceeding was held:________________________________ Case Number of court proceeding:__________________________ 22 __________ Through genetic testing, a copy of which is attached to this pleading. 23 __________ The child(ren) have the Father's last name. 24 V. 25 26 27 28 Child Support Print "YES" on each line in front of all of the statements that fit your circumstances and fill in the blanks regarding each of the "yes" answers. Print "N/A" (not applicable) on each line in front of all of the statements that do not fit your circumstances. 3 American LegalNet, Inc. www.FormsWorkflow.com 1 __________ I am paying child support directly to the other parent in the amount of $____________ per (circle one) week, month. __________ I am paying child support through the District Attorney's Office in the amount of $_______________ per (circle one) week, month. 5 __________ I am not paying child support. 6 __________ I am receiving child support directly from the other parent in the amount of $______________ per (circle one) week, month. __________ I am receiving child support through the District Attorney's Office in the amount of $_______________ per (circle one) week, month. __________ I am not receiving any child support. 11 __________ I am receiving welfare benefits for the child(ren). 12 __________ The child(ren) is (are) on Medicaid. 2 3 4 7 8 9 10 13 14 __________ The child(ren) is (are) currently covered by health insurance provided by __________________ and the premiums are $__________per ______________. (Mother or Father) (week or month) 15 16 17 I wish this Court to enter an Order for child support as follows: ___________________ shall pay child support to ______________________ in the amount of (Father or Mother) (Father or Mother) 18 19 20 $_________________ per month, per child, for a total of $_________________ per month, the payment to be due on or before the __________day of the month. 21 22 Print "YES" on every line in front of the statement that fits your circumstances. Print "no" on those lines that are not applicable to your set of circumstances. 23 24 25 This request is made based upon the following information: __________ The parent paying child support is unemployed and therefore the child support should be set at the minimum statutory requirement. __________ The parent paying child support is employed and earns $_______________ per (circle one) hour, day, week, month. 26 27 28 4 American LegalNet, Inc. www.FormsWorkflow.com 1 __________ The parent paying child support is capable of earning $________________ per (circle one) hour, day, week, month but is currently unemployed and the child support should be set at the minimum statutory amount until employed and then the support should be reviewed. __________ The parent paying child support is capable of earning $ ________________ per (circle one) hour, day, week, month, but is currently unemployed or underemployed and should pay the statutory amount. __________ The child support should be more than the statutory amount because: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________ The child support should be less than the statutory amount because: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 2 3 4 5 6 7 8 9 10 11 12 VI. 13 14 To my knowledge, the following custody and visitation orders have been entered regarding the 15 child(ren): 16 17 If any kind of custody or visitation orders have ever been filed, including orders in Temporary Protective Orders, regarding the child(ren), state the provisions of the orders. If no orders have ever been filed print "NONE" in the space. 18 19 ______________________________________________________________________________ 20 ______________________________________________________________________________ 21 ______________________________________________________________________________ 22 ______________________________________________________________________________ 23 VII. 24 25 26 27 Up to the present time, ____________________ has been the primary caretaker and (Mother or Father) physical custodian of the child(ren). I request that this Court enter a custody order granting the following: 28 5 American LegalNet, Inc. www.FormsWorkflow.com 1 2 Print "YES" in the ONE space that describes the kind of custody you want the court to order. Print "NO" in all the other spaces. 3 4 Joint legal and joint physical custody to the Petitioner and the Respondent. __________ Joint legal custody to the parties with primary physical custody to the Petitioner. __________ 5 __________ Joint legal custody to the parties with primary physical custody to the Respondent __________ Other: ____________________________________________________________ __________________________________________________________________ 6 7 8 9 VIII. 10 11 12 13 Fully explain the type of contact both parents have had with the child(ren), including physical contact, telephone contact, etc. Mother has had contact with the child(ren) in the following way: 14 ______________________________________________________________________________ 15 16 ______________________________________________________________________________ 17 ______________________________________________________________________________ 18 ______________________________________________________________________________ 19 ______________________________________________________________________________ 20 ______________________________________________________________________________ 21 22 Father has had contact with the child(ren) in the following way: 23 ______________________________________________________________________________ 24 ______________________________________________________________________________ 25 ______________________________________________________________________________ 26 ______________________________________________________________________________ 27 28 ______________________________________________________________________________ 6 American LegalNet, Inc. www.FormsWorkflow.com 1 2 3 4 5 6 7 8 9 10 REGULAR WEEKLY/MONTHLY EXCHANGE AND VISITATION Visitation must be set out in specific detail, including a full weekly or monthly schedule with the days the exchanges will take place, the times of the exchanges, and who will provide transportation. Without very specific visitation, an order will not be granted. Terms such as "reasonable visitation" and "visitation at reasonable times and places" will not be accepted. If you are requesting supervised visitation, be very specific as to who is going to act as supervisor. I wish this Court to enter an Order for regular, specific, weekly/monthly visitation and exchange of my child(ren) as follows: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 11 12 ______________________________________________________________________________ ______________________________________________________________________________ 13 ______________________________________________________________________________ 14 ______________________________________________________________________________ 15 ______________________________________________________________________________ 16 ______________________________________________________________________________ 17 ______________________________________________________________________________ 18 ______________________________________________________________________________ 19 20 21 22 ______________________________________________________________________________ HOLIDAY VISITATION (You may add or subtract any holidays on the following list. If you choose not to exchange the child/ren on a specific holiday, print “N/A” in the spaces for that holiday. If no changes for the holidays are to be made in the regular visitation schedule, state that clearly in the next paragraph and print “not applicable” on the lines provided for the individual holidays.) 23 24 25 26 27 28 The major holidays will be handled in the following manner: (Name each specific holiday, such as Thanksgiving, Christmas, Easter, Passover, Hanukkah) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 7 American LegalNet, Inc. www.FormsWorkflow.com 1 ______________________________________________________________________________ 2 ______________________________________________________________________________ 3 ______________________________________________________________________________ 4 ______________________________________________________________________________ 5 ______________________________________________________________________________ 6 ______________________________________________________________________________ 7 ______________________________________________________________________________ 8 New Year’s Day will be alternated with___________________________ having the child(ren) (Father or Mother) in the year _________ and each ______________year thereafter. (odd or even) 9 10 11 Martin Luther King’s Birthday will be alternated with________________ having the child(ren) (Father or Mother) 12 13 14 15 16 17 18 19 20 21 22 23 24 in the year _________ and each ______________year thereafter. (odd or even) President’s Day will be alternated with______________________ having the child(ren) in the (Father or Mother) year _________ and each ______________year thereafter. (odd or even) Memorial Day will be alternated with______________ having the child(ren) in the year (Father or Mother) _________ and each ______________year thereafter. (odd or even) Fourth of July will be alternated with_________________ having the child(ren) in the year (Father or Mother) _________ and each ______________year thereafter. (odd or even) Labor Day will be alternated with _______________________having the child(ren) in the year (Father or Mother) _________ and each ______________year thereafter. (odd or even) 25 26 27 28 Nevada Day will be alternated with______________ having the child(ren) in the year ________ (Father or Mother) and each ______________year thereafter. (odd or even) 8 American LegalNet, Inc. www.FormsWorkflow.com 1 2 3 4 5 6 Halloween will be alternated with_____________ having the child in the year _______________ (Father or Mother) and each ______________year thereafter. (odd or even) Veteran’s Day will be alternated with________________ having the child in the year _________ (Father or Mother) and each ______________year thereafter. (odd or even) 7 8 9 10 11 12 Child’s birthday will be alternated with ____________________having the child in the year (Father or Mother) _________ and each ______________year thereafter. (odd or even) __________ Mother shall have the child on Mother’s Day and Father shall have the child on Father’s Day. __________ Holidays not specifically time defined shall begin at ________ a.m. and end at 13 ________ p.m. on that same day. The parent who has the holiday will pick the 14 child up and return the child to the other parent at the end of the scheduled time. 15 Should a holiday fall on a three day weekend and it is the other parent’s weekend to have 16 17 18 19 the child(ren), the three day holiday will be handled as follows: _____________________________________________________________________________ _____________________________________________________________________________ 20 ______________________________________________________________________________ 21 ______________________________________________________________________________ 22 ______________________________________________________________________________ 23 ______________________________________________________________________________ 24 25 _______________________shall have a block time of time with the child(ren) for vacation (Father or Mother or both parents) 26 27 28 purposes. That length of time for vacation period shall be _______________________________ (one week, two weeks, three weeks, one month) 9 American LegalNet, Inc. www.FormsWorkflow.com 1 2 3 4 5 6 __________________ shall notify the other parent, in writing, at least __________________ (Father or Mother) (days or weeks) in advance of the choice of time. WHEREFORE, Petitioner prays that this Court enter an Order granting Petitioner's requests regarding custody, visitation and support as set forth above. Date:__________________________________ 7 ____________________________________ (Print name) 8 9 ____________________________________ (Signature) 10 11 12 ____________________________________ (Address) 13 ____________________________________ 14 Telephone:___________________________ 15 SUBSCRIBED and SWORN to before me 16 17 this ________day of _______________, 200___ 18 19 20 ________________________________________ NOTARY PUBLIC 21 22 23 24 25 26 27 28 10 American LegalNet, Inc. www.FormsWorkflow.com 1 2 VERIFICATION AND ACKNOWLEDGMENT STATE OF NEVADA ) )ss: ) 3 County of Washoe 4 ____________________________________, being first duly sworn, deposes and says 5 6 under penalty of perjury: 7 8 That he/she is the Petitioner herein; that he/she has read the Petition To Establish Custody and Visitation attached and knows the contents thereof and that the same is true of his/her own 9 knowledge, except as to the matters stated therein on information and belief, and as to those 10 11 matters, he/she believes them to be true. 12 13 ___________________________________ SUBSCRIBED and SWORN to before me 14 this _______day of___________________, __________ 15 16 __________________________________ NOTARY PUBLIC 17 18 STATE OF NEVADA 19 County of Washoe ) )ss: ) 20 On this _______________________, ________ personally appeared before me, the undersigned, 21 22 a Notary Public in and for the County of Washoe, State of Nevada, 23 _____________________________________________ personally known to me or proved to me 24 to be the person whose name is subscribed to the above instrument who acknowledged that 25 he/she executed the above instrument. 26 27 28 ______________________________________ NOTARY PUBLIC 11 American LegalNet, Inc. www.FormsWorkflow.com 1 SECOND JUDICIAL DISTRICT COURT COUNTY OF WASHOE, STATE OF NEVADA 2 3 AFFIRMATION Pursuant to NRS 239B.030 4 The undersigned does hereby affirm that the preceding document, 5 6 7 (Title of Document) 8 9 filed in case number: 10 Document does not contain the social security number of any person 11 -OR- 12 Document contains the social security number of a person as required by: 13 A specific state or federal law, to wit: 14 ______________________________________________________ (State specific state or federal law) 15 16 -or- 17 For the administration of a public program 18 -or- 19 For an application for a federal or state grant 20 -or- 21 Confidential Family Court Information Sheet (NRS 125.130, NRS 125.230 and NRS 125B.055) 22 23 24 Date: (Signature) 25 26 (Print Name) 27 28 (Attorney for) Affirmation Revised December 15, 2006 American LegalNet, Inc. www.FormsWorkflow.com