1 Code: 4050 Name:_________________________ 2 Address:_______________________ ______________________________ 3 Telephone:_____________________ 4 Name:_________________________ Address:_______________________ 5 ______________________________ Telephone:_____________________ 6 Acting In Proper Person 7 IN THE FAMILY DIVISION 8 OF THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA 9 IN AND FOR THE COUNTY OF WASHOE 10 __________________________________, 11 Plaintiff/Petitioner, Case No. ___________________ 12 vs Dept. No. __________________13 __________________________________, 14 Defendant/Petitioner/Respondent. 15 ________________________________________/ 16 STIPULATION MODIFYING CHILD RELATED ORDERS 17 IT IS HEREBY STIPULATED AND AGREED, by and between ________________________ (Plaintiff/Petitioners18 _____________________ and _____________________________________ , the parties in this matter,19 name) (Defendant/Petitioner/Respondents name) 20 that the orders now existing, which were entered on _________________________________ regarding (Date the order was entered that you are modifying)21 the child(ren) in this matter, namely: 22 NAME DATE OF BIRTH23 _______________________________________ ______________________________24 _______________________________________ ______________________________25 _______________________________________ ______________________________26 _______________________________________ ______________________________27 _______________________________________ ______________________________28 Ct. 1/00 1 >>>> 2 1 be modified, or changed, as follows: 2 3 Be very specific and detailed as to how you want the order changed. For each part of the order 4 or decree that you want to change, first, identify the part of the document to be changed, and second, state the change you are agreeing to. If the change is a new addition to the order or 5 decree, state the fact that it is to be added to the order or decree. (See instructions for examples of proper wording) 6 7 __________________________________________________________________________________ 8 _________________________________________________________________________________ 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Ct. 1/00 2>>>> 3 1 2 3 4 5 6 7 8 9 (If more room is needed, you may attach additional paper. Be sure each page is clearly10 identified as a continuance of the Stipulation and each page is initialed by both parties)11 All other provisions, except those modified, shall remain as stated in the prior order(s).12 The parties hereby certify that they are not represented by counsel in this matter and, if they have 13 been previously represented by counsel in this matter, that counsel has formally withdrawn from this14 case 15 by having filed with the Court either a formal Withdrawal of Counsel or a Substitution of Counsel,16 stating the party now represents themselves. 17 Dated:_________________________________ Dated:_________________________________ 18 19 ______________________________________ _______________________________________ (Print Name) (Print Name) 20 ______________________________________ _______________________________________ 21 (Signature) (Signature) 22 SUBSCRIBED and SWORN to before me SUBSCRIBED and SWORN to before me23 this ________day of ________________, ______.this________day of _________ _______,24 ______ 25 26 _______________________________________________________________________________ 27 NOTARY PUBLIC NOTARY PUBLIC28 Ct. 1/00 3