1 Case No. _____________ Dept. No _____________ 2 IN THE JUSTICE COURT OF _________________________ TOWNSHIP 3 COUNTY OF ___________________________, STATE OF NEVADA 4 5 _________________________________, Applicant, EXTENDED ORDER FOR PROTECTION AGAINST DOMESTIC VIOLENCE 6 vs. Date Issued: ___________ 7 8 _________________________________, Adverse Party. Date Expires: ___________ 9 10 VIOLATION OF THIS ORDER IS A CRIME 11 YOU, THE ADVERSE PARTY, ARE NOTIFIED THAT YOU CAN BE ARRESTED even if the person who obtained this Order invites or allows you to contact him or her. You have the sole responsibility to avoid or refrain from violating the terms of this Order. Only the Court can change this Order upon written application. 12 13 14 15 16 17 18 19 20 21 22 YOU ARE FURTHER NOTIFIED THAT IF YOU ARE ARRESTED FOR VIOLATING THIS ORDER, you will not be admitted to bail sooner than 12 hours after your arrest if: (1) the arresting officer determines that the violation is accompanied by a direct or indirect threat of harm; or (2) you have previously violated a temporary or extended order for protection of the type for which you have been arrested; or (3) at the time of the violation or within 2 hours after the violation, you have: (a) a concentration of alcohol of 0.08 or more in your blood or breath; or (b) an amount of a prohibited substance in your blood or urine that is equal to or greater than the amount set forth in subsection 3 of NRS 484.379. YOU ARE FURTHER NOTIFIED that child stealing/kidnapping is a felony. THIS ORDER is valid and enforceable throughout the State of Nevada. This Order meets all Full Faith and Credit provisions of the Violence Against Women Act, and is enforceable in all 50 states, the District of Columbia, U.S. Territories, and Indian Nations. All other courts and law enforcement agencies with jurisdiction within the United States and all Indian Nations shall give full faith and credit to this Order pursuant to 18 U.S.C. § 2265. 23 24 25 26 Possession, shipment, transportation, or receipt of a firearm or ammunition while this Order is in effect may constitute a felony under federal law 18 USC § 922(g)(8), and is punishable by a fine of up to $250,000 and/or a prison sentence of up to ten (10) years. Further, if prohibited by this Order, possession, custody, or control of a firearm while this Order is in effect is a gross misdemeanor under NRS Chapter 33. 27 The Court having considered the filings, testimony, and any evidence presented at hearing, and the 28 Court having found that the above-named Adverse Party received actual notice of hearing at which such 1 American LegalNet, Inc. www.FormsWorkflow.com 1 person had an opportunity to participate, and the Adverse Party 2 represented by counsel, __________________________________, and the above-named Applicant 3 4 was present was not present was present was not present was was represented by counsel, ________________________________, and the Court having jurisdiction over the parties and this matter pursuant to NRS 33.010, et seq., and it appearing to the satisfaction of the Court from specific facts shown that an act of domestic violence has 5 occurred, there exists a threat of domestic violence, and/or you represent a credible threat to the physical 6 7 safety of the Applicant or the minor child(ren), the Court enters this Order, and as a result: YOU ARE PROHIBITED, either directly or through an agent, from threatening, physically 8 injuring, or harassing the Applicant and/or the minor child(ren). YOU ARE FURTHER 9 PROHIBITED from selling, damaging, destroying, giving away, or otherwise disposing of, or 10 tampering with, any property owned by the Applicant, or in which the Applicant has an interest; YOU ARE PROHIBITED from any contact whatsoever with the Applicant, but not 11 limited to, in person, by telephone, through the mail, through electronic mail (e-mail), facsimile, or 12 through another person. 13 14 15 16 1. _____ Applicant’s residence located in __________________, County, Nevada, CONFIDENTIAL, or at: ______________________________________________, _________________________________, (Street) 17 18 YOU ARE EXCLUDED AND ORDERED to stay at least 100 yards away from (City) or any other place that Applicant may reside. YOU shall not interfere with Applicant’s possession and use of the residence, including utilities, phones, leases, and other related residential services; 19 2. _____ The Court, having jurisdiction under and meeting the requirements of Chapter 125A 20 of the Nevada Revised Statutes (UCCJA), grants to the Applicant temporary custody of the following 21 minor child(ren) of the parties: ____________________________________________________________ 22 _____________________________________________________________________________________ 23 ____________________________________________________________________________________; 24 YOU ARE PROHIBITED from interfering with the Applicant’s custody of the minor child(ren) 25 named in this paragraph. It is in the best interest of the child(ren) that no negative, insulting, or disparaging comments be made by one party against the other party in the presence of the minor 26 child(ren). 27 28 2 American LegalNet, Inc. www.FormsWorkflow.com 1 3. _____ YOU ARE GRANTED visitation with the minor child(ren): ___________________ 2 ____________________________________________________________________________________, 3 under the following terms and conditions: ___________________________________________________ 4 _____________________________________________________________________________________ _____________________________________________________________________________________ 5 ____________________________________________________________________________________. 6 7 8 4. _____ YOU ARE ORDERED to pay support and maintenance of the minor child(ren) as set forth in the attached Child Support Addendum. 9 5. _____ YOU ARE ORDERED to pay the rent or make payments on a mortgage on the 10 Applicant’s place of residence or pay towards the support and maintenance of the Applicant, as follows: 11 ____________________________________________________________________________________ 12 ____________________________________________________________________________________ 13 ____________________________________________________________________________________ 14 ____________________________________________________________________________________. 15 6. _____ Custody, visitation, and support of the minor child(ren) of the parties shall remain as 16 ordered in the Decree of Divorce/Order entered between the parties in Case Number ________________ 17 in the ______________________________________ Court of the State of _______________________. 18 19 7. ______ YOU ARE EXCLUDED AND ORDERED to stay at least 100 yards away from the minor child(ren)’s school(s), or day care, including, but not limited to, the places listed below: 20 21 CONFIDENTIAL 22 (a) Name of School______________________________________________________________ 23 Address_______________________________________________________________________ 24 City________________________________County ___________________ Nevada. 25 26 (b) Name of School______________________________________________________________ 27 Address_______________________________________________________________________ 28 City______________________________County ______________________Nevada. 3 American LegalNet, Inc. www.FormsWorkflow.com 1 (c) Name of School______________________________________________________________ 2 Address________________________________________________________________________ 3 City______________________________County ______________________ Nevada. 4 5 6. ________ YOU ARE EXCLUDED AND ORDERED to stay at least 100 yards away from 6 these place(s) of employment or any other place that Applicant may be employed. YOU ARE 7 PROHIBITED from any contact whatsoever with these place(s) of employment in person, by telephone, 8 by mail, or any other means of communication. CONFIDENTIAL 9 10 (a) Name_________________________________Address_______________________________ 11 City________________________________County ____________________ Nevada. 12 13 14 (b) Name________________________________Address_______________________________ 15 City______________________________County ______________________Nevada. 16 17 18 (c) Name_________________________________Address_______________________________ City______________________________County ____________________ Nevada. 19 20 9. _____ YOU ARE EXCLUDED AND ORDERED to stay at least 100 yards away from 21 the following places frequented regularly by Applicant and/or the minor child(ren): 22 23 (a) Name_________________________________Address_______________________________ 24 City_______________________________County ____________________ Nevada. 25 26 27 (b) Name_________________________________Address______________________________ City_______________________________County ____________________ Nevada. 28 4 American LegalNet, Inc. www.FormsWorkflow.com 1 (c) Name_________________________________Address_______________________________ 2 City_______________________________County ____________________ Nevada. 3 4 (d) Name_________________________________Address______________________________ 5 City_______________________________County ____________________ Nevada. 6 7 8 9 10 11 12 13 10. (a) ______ YOU ARE PROHIBITED, either directly or through an agent, from physically injuring or threatening to injure any animal that is owned or kept by the Applicant, the minor child(ren), or YOU. (b)______ YOU ARE PROHIBITED, either directly or through an agent, from taking possession of any animal owned or kept by the Applicant or the minor child(ren). (c) ______The arrangements for the possession and care of any animal(s) referenced above are as follows: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________. 14 15 11. ______ YOU ARE ORDERED to comply with the attached Firearms Addendum. 16 17 12. ______The following provisions and exceptions are made a part of this Order:____________ ____________________________________________________________________________________ 18 ____________________________________________________________________________________ 19 ____________________________________________________________________________________ 20 ____________________________________________________________________________________ 21 ____________________________________________________________________________________ 22 ____________________________________________________________________________________ 23 ____________________________________________________________________________________ ____________________________________________________________________________________ 24 ____________________________________________________________________________________ 25 ____________________________________________________________________________________ 26 ____________________________________________________________________________________ 27 ____________________________________________________________________________________ 28 ____________________________________________________________________________________. 5 American LegalNet, Inc. www.FormsWorkflow.com 1 2 THIS ORDER WILL REMAIN IN EFFECT UNTIL 11:59 P.M. ON THE DATE SET FORTH ON PAGE 1 UNLESS THIS COURT ORDERS OTHERWISE. 3 The Adverse Party is ordered to pay all previously deferred court costs and fees of 4 $ _______________ payable to ______________________________ by ________________________. 5 (date) 6 Pursuant to NRS 33.030(2) the Adverse Party is ordered to pay $_______________ to 7 8 Applicant by _________________________. (date) 9 10 ORDER TO LAW ENFORCEMENT 11 A. Any law enforcement officer who has probable cause to believe a violation of any provision of 12 this Order has occurred is ordered to arrest the Adverse Party. Such party is to be charged with a criminal 13 violation of this Order in addition to any other criminal charges which may be justified. B. If such law enforcement officer cannot verify that the Adverse Party was served with a copy of 14 15 this Application and Order, the officer shall inform the Adverse Party of the following: (1) the specific terms of this Order; (2) that the Adverse Party now has notice of the provisions of this Order; (3) that a 16 violation of this Order will result in the Adverse Party’s arrest; and (4) the location of the Court that 17 issued the original Order and the hours during which the Adverse Party can obtain a copy of the Order. 18 The law enforcement officer shall then provide written proof of notice to the officer’s agency and to the 19 Court. 20 21 Dated: _______________ 22 ____________________________________ 23 Judge/Hearing Master 24 25 26 27 28 6 American LegalNet, Inc. www.FormsWorkflow.com 1 CHILD SUPPORT ADDENDUM 2 3 ______ YOU ARE ORDERED to pay the amount of $ ____________ for the support and maintenance of the minor child(ren): __________________________________________________________________________. 4 Payments shall commence on _____________________________ and be paid on the ____________day of each 5 month while this Order remains in effect. Arrears have not been addressed in this Order. If the Applicant wishes to 6 have the payments made through the District Attorney’s office, the Applicant may seek relief from the local District Attorney’s office. NOTICE: PAYMENT OF SUPPORT IS TO BE AS PROVIDED HEREIN, AND THE 7 GIVING OF GIFTS, OR THE PURCHASES OF FOOD, CLOTHING, AND THE LIKE WILL NOT FULFILL 8 THE OBLIGATION. 9 10 A. Adverse Party’s (Obligor’s) gross monthly income $ ___________: formula amount: __________ % equals $__________ per 11 month, other ________________________. The basis for deviation from the State formula is as follows: ___________________________________________________ 12 _________________________________________________________________________________ 13 _________________________________________________________________________________. 14 B. 15 Withholding of income for the payment of the support must be carried out immediately, or The Court finding good cause: _____________________________________________________ 16 withholding of income shall be postponed until such time as the Adverse Party (Obligor) becomes 30 17 days delinquent under this Order. Payments shall be made directly to the Applicant by mail, at the following address: __________________________________________________________________ 18 _________________________________________________________________________________, 19 20 21 22 unless a court order states otherwise. C. The Adverse Party (Obligor) shall provide health insurance coverage for the minor child(ren), if available, through an employer at a reasonable cost, and shall provide all necessary assistance to enable Applicant to obtain the medical benefits for the minor child(ren). The Adverse Party (Obligor) shall pay $_____________________ per month for a medical 23 24 25 insurance premium, payable to _______________________________________________________. The Adverse Party shall provide proof of medical insurance coverage including a medical identification card and FIVE claim forms, if necessary, to the Applicant by mail, at the following address: _________________________________________________________________, 26 within ______________ days of today’s date, ___________________________________________. 27 28 Both the Applicant and the Adverse Party shall split equally all medical expenses not covered by medical insurance. 7 American LegalNet, Inc. www.FormsWorkflow.com 1 FIREARMS ADDENDUM 2 Any violation of the following is a gross misdemeanor under Nevada law (NRS 33.031). 3 4 The Court has considered, among other factors: (1) whether you have a documented history of domestic violence; (2) whether you have used or threatened to use a firearm to injure or harass the Applicant, a 5 minor child, or any other person; (3) whether you have used a firearm in the commission or attempted 6 commission of any crime, and: ___________________________________________________________ 7 ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 8 9 10 11 12 Pursuant to Nevada Revised Statutes Chapter 33, THIS COURT ORDERS the following: 13 14 YOU ARE PROHIBITED from possessing or having under your custody or control any firearm while this Order is in effect. 15 16 17 18 19 20 21 22 Within 24 hours after service of this Order you shall: surrender sell transfer all firearms in your possession or under your custody or control to: ____________________________________________________________________________________ (transferee) You must contact law enforcement before approaching a law enforcement officer or law enforcement facility with firearm(s). Not later than 72 hours or 1 business day, whichever is later, after the surrender, sale, or transfer of such firearm(s), you shall provide a receipt to the Court from the transferee. The receipt shall include 23 the name and address of the transferee and a written description of each such firearm. 24 25 Other ____________________________________________________________________________ 26 ____________________________________________________________________________________ 27 ____________________________________________________________________________________ 28 ____________________________________________________________________________________. 8 Firearms Addendum No. 1 American LegalNet, Inc. www.FormsWorkflow.com 1 FIREARMS ADDENDUM 2 Any violation of the following is a gross misdemeanor under Nevada law (NRS 33.031). 3 This Court has considered, among other factors: (1) whether you have a documented history of domestic 4 violence; (2) whether you have used or threatened to use a firearm to injure or harass the Applicant, a 5 minor child(ren), or any other person; (3) whether you have used a firearm in the commission or 6 attempted commission of any crime, and: 7 ____________________________________________________________________________________ 8 ____________________________________________________________________________________ 9 10 11 12 ____________________________________________________________________________________. Pursuant to Nevada Revised Statutes Chapter 33, THIS COURT ORDERS the following: YOU ARE PROHIBITED from possessing or having under your custody or control any firearm while this Order is in effect. 13 14 15 Within 24 hours after service of this Order you shall: surrender sell transfer all firearms in your possession or under your custody or control to 16 17 ________________________________________________________________________________ (transferee) 18 19 You must contact law enforcement before approaching a law enforcement officer or law enforcement facility with firearm(s). 20 Not later than 72 hours or 1 business day, whichever is later, after the surrender, sale, or transfer of 21 such firearm(s), you shall provide a receipt to the Court from the transferee. The receipt shall include the 22 name and address of the transferee and a written description of each such firearm. 23 24 25 26 27 YOU ARE GRANTED a limited employment exception from the prohibition noted above because you have established that: (1) the possession or use of a firearm(s) is an integral part of your employment with: Name of Employer_________________________________________________________ 28 Firearms Addendum No. 2 9 American LegalNet, Inc. www.FormsWorkflow.com 1 Employer’s Representative__________________________________________________ 2 Employer’s Address_______________________________________________________ 3 Employer’s County, City, State______________________________________________ 4 Employer’s Telephone Number______________________________________________ 5 AND 6 (2) your employer agrees to store/safeguard your firearm(s) when you are not working, and 7 sufficient proof to that effect has been provided to the Court. The firearm(s) that you may possess while 8 you are working is/are: (for example: make, model, caliber, serial number, etc.) 9 ____________________________________________________________________________________________ 10 ____________________________________________________________________________________________ 11 ____________________________________________________________________________________________ 12 ____________________________________________________________________________________________ 13 ___________________________________________________________________________________________. 14 15 Other:____________________________________________________________________________________ 16 ____________________________________________________________________________________________ 17 ____________________________________________________________________________________________ 18 ___________________________________________________________________________________________. 19 20 21 22 23 24 25 26 27 28 Firearms Addendum No. 2 10 American LegalNet, Inc. www.FormsWorkflow.com