Fill and Sign the Instructions Please Provide All Information Known to You and Please Print Legibly

Form C-5 Confidential Order for Protection of Child ren Information (To be filled out by Applicant) ©2007 Nevada Supreme Court June 30, 2007 *CONFIDENTIAL * ORDER FOR PROTECTION OF CHILDREN INFORMATION (TO BE FILLED OUT BY APPLICANT) Instructions: Please provide all information known to you and pleas e print legibly. All requested information is helpful for service, even if the information is only partially known. Please note that if you do not provide an address for the Adverse Party, or if the sheriff/constable cannot effectuate service at the address you give, Applicant has the ultimate responsibility for having the A dverse Party served by private process server or other means. APPLICANT DATA Name: _____________________________________________________ ________________________________________________________________________ (Last) (First) (Middle) Address Mailing Address : (if different from above) __________________________________________________________________________________________________________ (Street Address) (Bldg/Apt #) (City) (State) (Zip Code) Phone: Home: Work: Cell: Name of Minor: __________________________________________________________________________________________ (L ast) ( Fir s t) ( Mid dle ) Other Name Used By Minor: _________________________________________________________________________ (Last) (First) (Middle) Additional Contact Person: ________________________ Phone: ____________Address: _________________________ ADVERSE PARTY DATA Full Name: Other Name Used: (Last) (First) (Middle) (Last) (First) (Middle) Relationship To Minor (if any): Date of Birth / / and/or Social Security No.: (M) (D) (Y) Last Known Home Address: (Street Address) (Bldg/Apt #) (City) (State) (Zip Code) Is this address difficult to find?  No  Yes If yes, please explain ______________________________ Mailing Address: (If different from above)________________________________________________________________________________________ (Street Address) (Bldg/Apt #) (City) (State) (Zip Code) Other Likely Address: (Street Address) (Bldg/Apt #) (City) (State) (Zip Code) Home Phone: ______________________________________________ Cell Phone: ______________________________ Occupation: Employer: Work Days: __________ Work Hours: _______ Work Phone: ____________ Work Address: (Street Address) (City) (State) (Zip Code) Hair Color: Eye Color: Height: Weight: Sex Race: Scars/Marks/Tattoos (Description and Location): Does the Adverse Party speak English? (Yes or No) _____ If not, what language? Vehicle Make: ________ Model: ________ Year: ________License Plate Number/State: ___________________________ (Circle one) Are the Minor and the Adverse Party living together now? Yes or No Are the Minor and the Adverse Party employed by the same employer? Yes or No Is the Adverse Party likely to react violently when served? Yes or No Is the Adverse Party likely to avoid service? Yes or No Does the Adverse Party have a Carrying Concealed Weapon (CCW) Permit? Yes or No Does the Adverse Party have access to weapons? Yes or No If yes, please describe type and location of weapon(s): Does the Adverse Party's history include (please circle): assau lt, assaults w/weapon, battery, mental health problems, drug/alc ohol abuse, outstanding/prior arrest warrants, safety issues? Explain: Do not write in this space. For court purposes only. Issuing Court ORI: NV______________ Court Case Number: _______________ Law Enforcement: Do not serve this sheet with documents to be delivered. Form C-5 Confidential Order for Protection of Child ren Information (To be filled out by Applicant) ©2007 Nevada Supreme Court June 30, 2007 *CONFIDENTIAL*