1 2 Case No. ___________________ Dept. No. ___________________ 3 IN THE JUSTICE COURT OF _____________ TOWNSHIP 4 COUNTY OF __________________, STATE OF NEVADA 5 6 7 8 9 10 11 APPLICATION FOR ORDER FOR _____________________________________ PROTECTION OF CHILDREN ) (NRS 33.400) Applicant(s) ) ) vs. ) _____________________________________ ) Adverse Party(s)) (must be Age 18 or older).) 12 13 14 15 - In addition to any other remedy provided by law, the parent or guardian of a child may petition any court of competent jurisdiction on behalf of the child for a temporary or extended Order against a person who is 18 years of age or older and who the parent or guardian reasonably believes has committed or is committing a crime involving: (a) Physical or mental injury to the child of a nonaccidental nature; or (b) Sexual abuse or sexual exploitation of the child. (NRS 33.400) ORDER FOR PROTECTION OF CHILDREN 16 17 PLEASE TYPE OR PRINT CLEARLY. 18 19 20 21 22 23 24 COMPLETE THE APPLICATION TO THE BEST OF YOUR KNOWLEDGE. I am applying for protection (check all that apply):     For my minor child For my ward For my minor child and other person(s) For my ward and for other person(s) 25 Form C3 Application for Order for Protection of Children (NRS 33.400) Page 1 of 7 ©2007 Nevada Supreme Court June 30, 2007 1 Applicant states the following facts under penalty of perjury: 2 I reasonably believe that the Adverse Party has committed and/or is committing a crime 3 against a child as defined above. The acts occurred as follows: 4 5 6 (NOTE: BE SPECIFIC AS TO WHO COMMITTED WHAT ACTS, AGAINST WHOM, WHEN, WHERE, WHETHER COMMITTED OR THREATENED; INDICATE APPROXIMATE DATE(S) AND LOCATION(S).) 7 THIS FORM IS A PUBLIC RECORD 8 ______________________________________________________________________________ 9 ______________________________________________________________________________ 10 ______________________________________________________________________________ 11 ______________________________________________________________________________ 12 ______________________________________________________________________________ 13 ______________________________________________________________________________ 14 ______________________________________________________________________________ 15 ______________________________________________________________________________ 16 ______________________________________________________________________________ 17 ______________________________________________________________________________ 18 ______________________________________________________________________________ 19 ______________________________________________________________________________ 20 ______________________________________________________________________________ 21 ______________________________________________________________________________ 22 23 24 NOTE: PLEASE DO NOT WRITE ON THE BACKS OF ANY PAGES; CHECK BOX IF YOU ARE USING ADDITIONAL PAGES.  Check if you use a continuation page (to be incorporated by reference) 25 Form C3 Application for Order for Protection of Children (NRS 33.400) Page 2 of 7 ©2007 Nevada Supreme Court June 30, 2007 1 Has this matter been reported to law enforcement or child protective services? Yes 2 No 3 If yes, approximate date(s): 4 _____________________________________________________________________ 5 Name of agency: 6 _____________________________________________________________________ 7 Case/Event number if known: 8 _____________________________________________________________________ 9 (IF YOU HAVE A REPORT AVAILABLE, PLEASE ATTACH A COPY OR BRING IT TO THE COURT HEARING.) 10 11 12 13 14 For purposes of this form, a “TPO Action” is defined to include the following Justice Court actions: (1) An Order for Protection Against Stalking and Harassment (NRS 200.591); (2) An Order for Protection of Children (NRS 33.400); (3) An Order for Protection Against Harassment in the Workplace (NRS 33.270). A “TPO Action” is also defined to include the following Justice/Family/District Court action: (a) An Order for Protection Against Domestic Violence (NRS 33.020) Please Check the Appropriate Box Below: 15 16  17 18 19 20 21 22  In the last 2 years, Applicant or any party seeking protection has not filed a TPO action against the Adverse Party anywhere in the State of Nevada, and the Adverse Party has not filed a TPO action against Applicant or any party seeking protection anywhere in the State of Nevada. In the last 2 years, the following TPO action(s) in the State of Nevada have been filed involving Applicant and the Adverse Party: Case # (if known) Court Place of (Justice/Family) Filing Approx. Date Filed Outcome (TPO granted, denied, rescinded, etc.) 23 24 25 Form C3 Application for Order for Protection of Children (NRS 33.400) Page 3 of 7 ©2007 Nevada Supreme Court June 30, 2007 1 2 Has the Adverse Party ever been involved in any other relevant Court actions (e.g., eviction, divorce, custody, criminal, etc.)? Yes 3 No 4 If yes, please explain: ________________________________ _____________________________________________________________________ 5 _____________________________________________________________________ 6 _____________________________________________________________________ 7 Applicant must be at least 18 years of age. If not 18 years of age, consult with the Clerk. 8 9 1. a) Applicant’s Name Age ____________________________________________ (Last) (First) (Middle) _______ 10 11 12 13 14 15 16 17 18 19 b) Protected Minor’s Name Age ____________________________________________ (Last) (First) (Middle) _______ c) Protected Minor’s relationship to Applicant: _______________________________ Protected Minor’s relationship to Adverse Party: ___________________________ d) Applicant’s relationship to Adverse Party: _________________________________ e) Provide names below of those for whom you are additionally seeking protection, including family and household members that need this protection. Indicate the relationships of all persons listed to the minor and to the Adverse Party (i.e., spouse, intimate partner, friend, roommate, neighbor, relative, acquaintance, co-worker, stranger): 20 21 NAME OF OTHERS SEEKING PROTECTION AGE 22 RELATIONSHIP TO PROTECTED MINOR RELATIONSHIP TO ADVERSE PARTY 23 24 25 Form C3 Application for Order for Protection of Children (NRS 33.400) Page 4 of 7 ©2007 Nevada Supreme Court June 30, 2007 1 Explain why protection is needed for the individuals listed above: 2 ______________________________________________________________________________ 3 ______________________________________________________________________________ 4 ______________________________________________________________________________ 5 6 7 (NOTE: YOUR APPLICATION WILL NOT BE DENIED BASED UPON A PARTICULAR RELATIONSHIP. HOWEVER, DEPENDING UPON YOUR RELATIONSHIP, YOU MAY ALSO BE ELIGIBLE TO APPLY FOR AN ORDER OF PROTECTION AGAINST DOMESTIC VIOLENCE PURSUANT TO NRS CHAPTER 33.) 8 9 2. 3. 12 13 Yes No If so, for how long? _______________________________________________________ 10 11 Have the minor and the Adverse Party ever lived together? Is anyone listed on Page 4 living with the Adverse Party now? Yes No If so, who? ___________________________________ 4. Are there other children involved? Yes No. If so, how are they involved? 14 ________________________________________________________________________ 15 ________________________________________________________________________ 16 5. Residence(s) where protection is needed:  CONFIDENTIAL (If confidential, check and move to the next question) or,  If not confidential, list address, city, state and zip code: 17 18 19 ________________________________________________________________________ 20 ________________________________________________________________________ 21 22 23 6. Place(s) of employment where protection is needed:  CONFIDENTIAL (If confidential, check and move to the next question) or,  If not confidential, list name, address, city, state and zip code: ______________________________________________________________________________ 24 ______________________________________________________________________________ 25 Form C3 Application for Order for Protection of Children (NRS 33.400) Page 5 of 7 ©2007 Nevada Supreme Court June 30, 2007 1 7. School(s) where protection is needed:  CONFIDENTIAL, (If confidential, check and move to the next question): or,  If not confidential, list name, address, city, state and zip code: 2 3 4 ________________________________________________________________________ 5 ________________________________________________________________________ 6 8. Other specific locations frequented where protection is needed (i.e., sports, extra- 7 curricular activities, church, employment, after-school activities, etc.): 8  CONFIDENTIAL (If confidential, check and move to the next question) or,  If not confidential, list name, address, city, state and zip code: 9 10 ________________________________________________________________________ 11 ________________________________________________________________________ 12 ________________________________________________________________________ 13 9. If there are persons other than those listed on page 4 that the Adverse Party should be 14 directed not to contact, please name the individuals and explain why these precautions are 15 needed: ___________________________________________________________ 16 10. If there are any other safety concerns that the Court should know (i.e., firearms, etc.), 17 please briefly explain: _____________________________________________________ 18 ________________________________________________________________________ 19 ________________________________________________________________________ 20 ________________________________________________________________________ 21 ________________________________________________________________________ 22 23 RELIEF REQUESTED THEREFORE, I REQUEST that a Temporary Order be issued requiring the Adverse 24 Party to refrain from contacting, intimidating, threatening or otherwise interfering with the minor 25 and/or other persons identified in this application, either directly or through an agent. Form C3 Application for Order for Protection of Children (NRS 33.400) Page 6 of 7 ©2007 Nevada Supreme Court June 30, 2007 1 2 I FURTHER REQUEST that the Court require the Adverse Party to stay away from the places listed above. 3 I FURTHER REQUEST the following other conditions: ________________________ 4 ___________________________________________________________________________ 5 6 I FURTHER REQUEST that this Court set a hearing date for an Extended Order as soon as possible.  Yes  No 7 8 9 10 11 12 (NOTE: IF GRANTED AND SERVED, A TEMPORARY ORDER MAY BE ENFORCED FOR UP TO 30 DAYS, EXCEPT THAT IF AN EXTENDED ORDER IS REQUESTED, THE TEMPORARY ORDER REMAINS IN EFFECT UNTIL THE HEARING ON THE EXTENDED ORDER IS HELD BY THE COURT. IF GRANTED AND SERVED, AN EXTENDED ORDER MAY BE ENFORCED FOR UP TO ONE YEAR.) I ACKNOWLEDGE that an Extended Order may only be granted after notice of the petition for the Order and of the Hearing thereon is served upon the Adverse Party pursuant to the Rules of Civil Procedure, and a hearing is held on the petition. 13 DECLARATION (NRS 53.045) 14 15 I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAW OF THE STATE OF 16 NEVADA THAT: (1) I AM THE APPLICANT HEREIN, (2) I HAVE READ THE 17 STATEMENTS CONTAINED HEREIN OR HAVE HAD THEM READ TO ME, (3) I 18 BELIEVE THESE STATEMENTS TO BE TRUE, AND (4) THE REQUESTED ORDER IS 19 NEEDED. 20 Dated:___________________________ __________________________________ APPLICANT’S SIGNATURE __________________________________ PRINT NAME 21 22 23 24 25 Form C3 Application for Order for Protection of Children (NRS 33.400) Page 7 of 7 ©2007 Nevada Supreme Court June 30, 2007