REV 5/6/2019 JCB 1 D-21 PETITION 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Plaintiff / Petitioner, Defendant / Respondent. Code: 3645/$3645 Name: Address: Telephone: Email: Self-Represented Litigant IN THE FAMILY DIVISION OF THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA IN AND FOR THE COUNTY OF WASHOE , Case No. vs. Dept. No. , / PETITION FOR CHILD VISITATION 1. I petition this Court for an Order establishing specific visitation for the minor child(ren) namely: Child222s Name Date of Birth If more room is needed, attach additional sheets. 2. There IS 226OR226 IS NOT an active Washoe County Human Services Agency case regarding the minor child(ren). (CPS case) American LegalNet, Inc. www.FormsWorkFlow.com REV 5/6/2019 JCB 2 D-21 PETITION 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 3. My relationship to the minor child(ren) is (check all that apply): Grandparent Great-Grandparent Sibling I resided with the child(ren) and established a meaningful relationship. If none of these apply to you, please attend Lawyer in the Library or meet with a licensed attorney to determine if you should file this packet. 4. My current address is: 5. The parents of the minor child(ren) are: Parent 1: Parent 2: The parent(s) reside together at: 226OR226 Parent 1222s current address is: Parent 2222s current address is: 6. (Check all that apply, if any) A parent of the minor child(ren) is deceased. A parent is divorced or separated from the parent who has custody of the child(ren). The parents were never married, but lived together, and are now separated. A parent has relinquished their parental rights or their parental rights have been terminated, and the child(ren) is not in the custody of a public or private child placing agency. If none of these apply to you, please attend Lawyer in the Library or meet with a licensed attorney to determine if you should file this packet. American LegalNet, Inc. www.FormsWorkFlow.com REV 5/6/2019 JCB 3 D-21 PETITION 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Minor Child ( ren ) On the lines below: Provide the information requested regarding each minor child born to, or adopted by, both parents. You MUST LIST where the child currently lives, where the child has lived for the PAST 5 YEARS, and the name(s) and current address(es) of the person(s) with whom the child lived at each address. 7. If more room is needed, attach additional sheets. Child222s Name: Date of Birth: Male Female Date Child Moved Here Child222s Address (Street Address, City, State) Person (s) With Whom Child Lived (Name and Current Address) Relationship To Child Child222s Name: Date of Birth: Male Female Date Child Moved Here Child222s Address (Street Address, City, State) Person (s) With Whom Child Lived (Name and Current Address) Relationship To Child Child222s Name: Date of Birth: Male Female Date Child Moved Here Child222s Address (Street Address, City, State) Person (s) With Whom Child Lived (Name and Current Address) Relationship To Child American LegalNet, Inc. www.FormsWorkFlow.com REV 5/6/2019 JCB 4 D-21 PETITION 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 8. a. Please identify any other court case in which either party has participated as a party, witness, or in any other way concerning the custody of or visitation with the minor child(ren). If there are no other court cases, please check this box . Name(s) of minor child(ren) involved: Court: Case number: Date of custody determination: b. Please identify any court case that could affect this case, including any case relating to domestic violence, protective orders, termination of parental rights, adoptions, guardianships, dependency, and paternity actions. If there are no other court cases, please check this box . Name(s) of minor child(ren) involved: Court: Type of case: Case number: Date of last order: c. Please identify the name(s) and address(es) of any person(s) not a party to this court case who claim(s) a right to legal custody, physical custody or visitation with the minor child(ren). If this is not applicable, please check this box . Name(s) of minor child(ren) involved: Name(s) and address(es) of person(s) claiming custody or visitation rights: If more room is needed, attach additional sheets. American LegalNet, Inc. www.FormsWorkFlow.com REV 5/6/2019 JCB 5 D-21 PETITION 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 9. Up to the present time, I have had contact with the minor child(ren) in the following way: If more room is needed, attach additional sheets. 10. I have been denied or unreasonably restricted in my visitation with the minor child(ren) in the following way(s): If more room is needed, attach additional sheets. American LegalNet, Inc. www.FormsWorkFlow.com REV 5/6/2019 JCB 6 D-21 PETITION 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 11. I wish this court to enter an order for specific visitation as follows: If more room is needed, attach additional sheets. I ask that this Court enter an order granting my request regarding visitation as set forth in this petition. This document does not contain the personal information of any person as defined by NRS 603A.040. I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct. Date: Your Signature: Print Your Name: American LegalNet, Inc. www.FormsWorkFlow.com