Fill and Sign the Dc 1923 Form

Nebraska State Court Form DC 19:23 Rev. 11/17 Neb. Rev. Stat. § 28-311.09 REQUEST FOR MODIFICATION TO HARASSMENT PROTECTION ORDER IN THE DISTRICT COURT OF COUNTY, NEBRASKA ________________________________________ Petitioner, ________________________________________ Additional Petitioner/Minor Child(ren), ________________________________________ Case No. ____________________ Additional Petitioner/Minor Child(ren), vs. ________________________________________ Respondent. REQUEST FOR MODIFICATION TO HARASSMENT PROTECTION ORDER 1. I/We, ______________________________________, am/are the petitioner(s) in this case. I am requesting a modification to the existing harassment protection order issued on, , pursuant to Neb. Rev. Stat. § 28-311.09. 2. This request will apply to the following protected party(ies): 1.________________________________ 2.________________________________ 3.________________________________ 3. The modification(s) requested is/are detailed below: 4. Reasons for modification are stated below: Page 1 of 2 Request for Modification to Harassment Protection Order DC 19:23 Rev. 11/17 4.________________________________ 5.________________________________ 6.________________________________ NOTE: DO NOT SIGN UNTIL THE CLERK OF THE DISTRICT COURT OR A NOTARY IS PRESENT AND WITNESSES YOU SIGNING I hereby swear, or affirm, under penalty of perjury, the forgoing is true. *If you are concealing your address or phone, do not provide them. Make separate arrangements with the clerk. Date Signature of Petitioner Name *Street Address/P.O. Box Bar Number and Firm Name (attorneys only) City/State/ZIP Code Phone E-mail Address Subscribed and sworn before me on Clerk of the District Court/Notary Public My Commission Expires: ____________________ Page 2 of 2 Request for Modification to Harassment Protection Order DC 19:23 Rev. 11/17 , (Seal)