Fill and Sign the Applicants Nrs 33 Form

Form C3 Application for Or der for Protection of Child ren (NRS 33. 400) ©2007 Nevada Supr eme Cour t June 30, 200 7 Page 1 of 7 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 Case No. ___________________ Dept. No. ___________________ IN THE JUSTICE COURT OF _____________ TOWNSHIP COUNTY OF __________________, STATE OF NEVADA _____________________________________ Applicant(s) vs. _____________________________________ Adverse Party(s ) (must be A ge 18 or old er) . ) ) ) ) ) ) ) APPLICAT ION FOR ORDER F OR PROTECTION OF CHILDREN (NRS 33.400) ORDER F OR PROTE CTION OF CHILD REN - In additi on to any other rem edy provide d by law, the parent or gu ardi an o f a chi ld ma y peti tion an y c ourt of c ompe tent j urisdi ction o n beh alf of t he chi ld fo r a temp orar y or exte nded Ord er agai nst a person who is 18 years of age or ol der and w ho the paren t or gu ardi an re ason abl y bel ieves h as c ommi tted or is comm itting a cri me invol ving : (a) P hysic al or men tal i njur y to the c hild o f a n onaccident al n ature; or (b) Se xu al abu se or se xu al ex ploitation of the chi ld. (NRS 33 .400) PLEASE T YPE OR P RINT CLE ARL Y. COMPLETE THE AP PLICATION TO THE BEST OF YOUR KNOWLEDGE. I am applying for protection (c heck all that apply):  For my mi nor child  For m y ward  For m y m inor child and other person(s)  For m y ward and for other person (s) Form C3 Application for Order for Protection of Children (NRS 33.400) ©2007 Nevada Supreme Court June 30, 2007 Page 2 of 7 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 Applicant states the following facts under penalty of perjury: I reasonably believe that the Adverse Party has committed and/or is committing a crime against a child as defined above. The acts occurred as follows: (NOTE: BE SPECIFIC AS TO WHO COMMI TTED WHAT ACTS, AGAINST WHOM, WHEN, WHERE, WHETHER COMMITTE D OR THREATENED; INDICATE APPROXIMATE DATE(S) AND LOCATION(S).) THIS FORM IS A PUBLIC RECORD ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ NOTE: PLEASE DO NOT WRITE ON TH E BACKS OF ANY PAGES; CHECK BOX IF YOU ARE USING ADDITIONAL PAGES.  Check if you use a continuation page (to be incorporated by reference) Form C3 Application for Order for Protection of Children (NRS 33.400) ©2007 Nevada Supreme Court June 30, 2007 Page 3 of 7 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 Has this matter been reported to law en forcement or child protective services?  Yes  No If yes, approximate date(s): _____________________________________________________________________ Name of agency: _____________________________________________________________________ Case/Event number if known: _____________________________________________________________________ (IF YOU HAVE A REPORT AVAILABLE, PLEASE ATTACH A COPY OR BRING IT TO THE COURT HEARING.) For purposes of this form, a “TPO Acti on” is defined to include the following Justice Court actions: (1) An Order for Protection Agains t 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 Ag ainst Domestic Violence (NRS 33.020) Please Check the Appropriate Box Below:  In the last 2 years, Applicant or any part y seeking protection has not filed a TPO action against the Adverse Party anywhere in the St ate of Nevada, and the Adverse Party has not filed a TPO action against Applicant or a ny 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 (Justice/Family) Place of Filing Approx. Date Filed Outcome (TPO granted, denied, rescinded, etc.) Form C3 Application for Order for Protection of Children (NRS 33.400) ©2007 Nevada Supreme Court June 30, 2007 Page 4 of 7 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 Has the Adverse Party ever been involved in any other relevant Court actions (e.g., eviction, divorce, custody, criminal, etc.)?  Yes  No If yes, please explain: ________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Applicant must be at least 18 years of age. If not 18 years of age, consult with the Clerk. 1. a) Applicant’s Name Age ____________________________________________ _______ (Last) (First) (Middle) b) Protected Minor’s Name Age ____________________________________________ _______ (Last) (First) (Middle) c) Protected Minor’s relationship to Applicant: _______________________________ Protected Minor’s relations hip 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, acquain tance, co-worker, stranger): NAME OF OTHERS SEEKING PROTECTION AGE RELATIONSHIP TO PROTECTED MINOR RELATIONSHIP TO ADVERSE PARTY Form C3 Application for Order for Protection of Children (NRS 33.400) ©2007 Nevada Supreme Court June 30, 2007 Page 5 of 7 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 Explain why protection is needed for the individuals listed above: ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ (NOTE: YOUR APPLICATION WILL NOT BE DENIED BASED UPON A PARTICULAR RELATIONSHIP. HOWEVER, DEPENDING UPON YOUR RELATIONSHIP, YOU MAY ALSO BE ELI GIBLE TO APPLY FOR AN ORDER OF PROTECTION AGAINST DOMESTIC VI OLENCE PURSUANT TO NRS CHAPTER 33.) 2. Have the minor and the Advers e Party ever lived together?  Yes  No If so, for how long? _______________________________________________________ 3. 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? ________________________________________________________________________\ ________________________________________________________________________\ 5. Residence(s) where protection is needed:  CONFIDENTIAL (If confidential, check and move to the next question) or,  If not confidential, list addr ess, city, state and zip code: ________________________________________________________________________\ ________________________________________________________________________\ 6. Place(s) of employment wher e 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: ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ Form C3 Application for Order for Protection of Children (NRS 33.400) ©2007 Nevada Supreme Court June 30, 2007 Page 6 of 7 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 7. School(s) where protection is needed:  CONFIDENTIAL, (If confidential, check and move to the next question): or,  If not confidential, list name, a ddress, city, state and zip code: ________________________________________________________________________\ ________________________________________________________________________\ 8. Other specific locations frequented wher e protection is needed (i.e., sports, extra- curricular activities, church, employment, after-school activities, etc.):  CONFIDENTIAL (If confidential, check and move to the next question) or,  If not confidential, list name, a ddress, city, state and zip code: ________________________________________________________________________\ ________________________________________________________________________\ ________________________________________________________________________\ 9. If there are persons other than those liste d on page 4 that the Adverse Party should be directed not to contact, please name the i ndividuals and explain why these precautions are needed: ___________________________________________________________ 10. If there are any other safety concerns that the Court should know (i.e., firearms, etc.), please briefly explain: _______________________________________________\ ______ ________________________________________________________________________\ ________________________________________________________________________\ ________________________________________________________________________\ ________________________________________________________________________\ RELIEF REQUESTED THEREFORE, I REQUEST that a Temporary Order be issued requiring the Adverse Party to refrain from contacting, intimidating, thr eatening or otherwise interfering with the minor and/or other persons identified in this application, either di rectly or through an agent. Form C3 Application for Order for Protection of Children (NRS 33.400) ©2007 Nevada Supreme Court June 30, 2007 Page 7 of 7 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 I FURTHER REQUEST that the Court require the Advers e Party to stay away from the places listed above. I FURTHER REQUEST the following other conditions: ________________________ ____________________________ _______________________________________________ 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 EFFE CT UNTIL THE HEARING ON THE EXTENDED ORDER IS HELD BY THE COURT. IF GRANTED AND SERVED, AN EXTENDED ORDER MAY BE ENFO RCED FOR UP TO ONE YEAR.) I ACKNOWLEDGE that an Extended Order may only be gr anted after notice of the petition for the Order and of the Hearing thereon is served upon th e Adverse Party pursuant to the Rules of Civil Procedure, and a hearing is held on the petition. DECLARATION (NRS 53.045) I DECLARE UNDER PENALTY OF PERJUR Y UNDER THE LAW OF THE STATE OF NEVADA THAT: (1) I AM THE APPLICANT HEREIN, (2) I HAVE READ THE STATEMENTS CONTAINED HEREIN OR H AVE HAD THEM READ TO ME, (3) I BELIEVE THESE STATEMENTS TO BE TR UE, AND (4) THE REQUESTED ORDER IS NEEDED. Dated:___________________________ __________________________________ APPLICANT’S SIGNATURE __________________________________ PRINT NAME