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 _____________________________________ ) Applicant(s),) APPLICATION FOR ORDER FOR ) PROTECTION AGAINST STALKING, vs. ) AGGRAVATED STALKING, _____________________________________ ) OR HARASSMENT (NRS 200.591) Adverse Party(s).) ) ) 11 12 13 14 15 16 17 STALKING - A person commits the crime of stalking when, without lawful authority, that person willfully or maliciously engages in a course of conduct that would cause a reasonable person to feel terrorized, frightened, intimidated or harassed, and that actually causes the victim to feel terrorized, frightened, intimidated or harassed. (NRS 200.575 (1)) AGGRAVATED STALKING - A person commits the crime of aggravated stalking when that person commits the crime of stalking and, in conjunction therewith, threatens the person with the intent to cause him to be placed in reasonable fear of death or substantial bodily harm. (NRS 200.575 (2)) HARASSMENT - A person commits the crime of harassment when (a) that person, without lawful authority, knowingly threatens: (1) to cause bodily injury in the future to the person threatened or to any other person; (2) to cause physical damage to the property of another person; (3) to subject the person threatened or any other person to physical confinement or restraint; or (4) to do any act which is intended to substantially harm the person threatened or any other person with respect to his physical or mental health or safety; and (b) the person by words or conduct places the person receiving the threat in reasonable fear that the threat will be carried out. (NRS 200.571) 18 19 PLEASE TYPE OR PRINT CLEARLY. 20 COMPLETE THE APPLICATION TO THE BEST OF YOUR KNOWLEDGE. 21 22 23 I am applying for protection (check all that apply): ͕ For Myself ͕ On behalf of another person(s) 24 25 ©2007 Nevada Supreme Court June 30, 2007 Form A3-Application for Order for Protection Against Stalking, Aggravated Stalking, or Harassment (NRS 200.591) Page 1 of 7 1 Applicant states the following facts under penalty of perjury: 2 I reasonably believe that the Adverse Party has committed and/or is committing the 3 crime of stalking, aggravated stalking or harassment as defined above. The acts occurred as 4 follows: 5 6 (NOTE: BE SPECIFIC AS TO WHO COMMITTED WHAT ACT OR 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 NOTE: PLEASE DO NOT WRITE ON THE BACKS OF ANY PAGES; CHECK BOX IF YOU ARE USING ADDITIONAL PAGES. 22 ͕ Check if you use a continuation page (to be incorporated by reference) 23 24 This matter does not have to be reported to law enforcement; however, has a report ever been 25 filed? ͕ Yes ͕ No ©2007 Nevada Supreme Court June 30, 2007 Form A3-Application for Order for Protection Against Stalking, Aggravated Stalking, or Harassment (NRS 200.591) Page 2 of 7 1 If yes, approximate date(s): 2 _____________________________________________________________________ 3 Name of law enforcement agency: _____________________________________________________________________ 4 Case/Event number if known: 5 6 7 8 9 10 11 _____________________________________________________________________ (NOTE: IT IS NOT NECESSARY TO FILE A LAW ENFORCEMENT REPORT, BUT IF YOU HAVE ONE AVAILABLE, PLEASE ATTACH A COPY OR BRING IT TO THE COURT HEARING.) 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) 12 Please Check the Appropriate Box Below: 13 ͕ 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 # Court Place of Approx. Outcome (TPO (if known) (Justice/Family) Filing Date Filed granted, denied, rescinded, etc.) 14 15 16 17 18 19 20 21 22 Applicant must be at least 18 years of age. If not 18 years of age, consult with the Clerk. 23 1. 24 25 a) Applicant’s Name Age ____________________________________________ (Last) (First) (Middle) _______ ©2007 Nevada Supreme Court June 30, 2007 Form A3-Application for Order for Protection Against Stalking, Aggravated Stalking, or Harassment (NRS 200.591) Page 3 of 7 1 b) Applicant’s relationship to Adverse Party: ________________________________ 2 c) Provide names below of those for whom you are seeking protection, including 3 yourself, minors or household members that need this protection. Indicate the relationships of 4 all persons listed to yourself and to the Adverse Party (e.g., spouse, intimate partner, friend, 5 6 roommate, neighbor, relative, acquaintance, co-worker, stranger): 7 NAME AGE 8 RELATIONSHIP TO APPLICANT RELATIONSHIP TO ADVERSE PARTY Self (if applicable) 9 10 11 12 13 14 15 16 17 18 19 Explain why protection is needed for the individuals listed above: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 21 (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.) 22 2. 20 25 ͕ Yes ͕ No If so, for how long? ____________________________ 23 24 Has the Adverse Party ever lived with any Party listed above? 3. Is anyone listed above living with the Adverse Party now? ͕ Yes ͕ No If so, who? ___________________________________ ©2007 Nevada Supreme Court June 30, 2007 Form A3-Application for Order for Protection Against Stalking, Aggravated Stalking, or Harassment (NRS 200.591) Page 4 of 7 1 4. Date of separation (if applicable): _______________________________________ 2 5. Are there children involved? ͕ Yes ͕ No If so, how are they involved? 3 ___________________________________________________________________ 4 ___________________________________________________________________ 5 6. Has the Adverse Party ever been involved in any other relevant Court actions (e.g., 6 eviction, divorce, custody, criminal, etc.)? 7 ͕ Yes ͕ No If yes, please explain: ____________________________________ 8 ___________________________________________________________________________ 9 ___________________________________________________________________________ 10 ___________________________________________________________________________ 11 7. 12 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: 13 14 _____________________________________________________________________ 15 _____________________________________________________________________ 16 8. 17 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: 18 19 ___________________________________________________________________________ 20 _______________________________________________________________ 21 9. 22 23 Location of 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: 24 _____________________________________________________________________ 25 _____________________________________________________________________ ©2007 Nevada Supreme Court June 30, 2007 Form A3-Application for Order for Protection Against Stalking, Aggravated Stalking, or Harassment (NRS 200.591) Page 5 of 7 1 10. 2 curricular activities, church, employment, after-school activities, etc.): 3 Other specific locations frequented where protection is needed (i.e., sports, extra- 4 5 ͕ CONFIDENTIAL (If confidential, check and move to the next question) or, ͕ If not confidential, list name, address, city, state and zip code: _____________________________________________________________________ 6 7 _____________________________________________________________________ 11. If there are persons other than those listed on page 4 that the Adverse Party should be 8 directed not to contact, please name the individuals and explain why these precautions 9 are needed: ___________________________________________________________ 10 _____________________________________________________________________ 11 12. If there are any other safety concerns that the Court should know (e.g., firearms, etc.), 12 please briefly explain: 13 ____________________________________________________________________________ 14 ____________________________________________________________________________ 15 16 17 RELIEF REQUESTED THEREFORE, I REQUEST that a Temporary Order be issued against the Adverse 18 Party requiring the Adverse Party to refrain from contacting, intimidating, threatening or 19 otherwise interfering with me and/or other persons identified in this application, either 20 directly or through an agent. 21 22 I FURTHER REQUEST that the Court require the Adverse Party to stay away from the places listed above. 23 24 25 ©2007 Nevada Supreme Court June 30, 2007 Form A3-Application for Order for Protection Against Stalking, Aggravated Stalking, or Harassment (NRS 200.591) Page 6 of 7 1 I FURTHER REQUEST the following other conditions: 2 __________________________________________________________________________ 3 _______________________________________________________________________________ 4 5 6 7 8 9 10 11 12 __________________________________________________________________________________ __________________________________________________________________________________ I FURTHER REQUEST that this Court set a hearing date for an Extended Order as soon as possible. ͕Yes ͕ No (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 14 15 DECLARATION (NRS 53.045) 16 I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAW OF THE STATE OF 17 NEVADA THAT: (1) I AM THE APPLICANT HEREIN, (2) I HAVE READ THE STATEMENTS 18 CONTAINED HEREIN OR HAVE HAD THEM READ TO ME, (3) I BELIEVE THESE 19 STATEMENTS TO BE TRUE, AND (4) THE REQUESTED ORDER IS NEEDED. 20 Dated:___________________________ __________________________________ APPLICANT’S SIGNATURE _______________________________ PRINT NAME 21 22 23 24 25 ©2007 Nevada Supreme Court June 30, 2007 Form A3-Application for Order for Protection Against Stalking, Aggravated Stalking, or Harassment (NRS 200.591) Page 7 of 7