Fill and Sign the Las Vegas Justice Court Township Form

1 1 23 4 56789 1011 12 13141516171819202122232425262728 Case No. __________Dept. No. __________ IN THE JUSTICE COURT OF ________________________ TOWNSHIP COUNTY OF _____________________, STATE OF NEVADA _______________________________________, Applicant, vs. APPLICATION FOR A TEMPORARY AND/OR EXTENDED ORDER FOR PROTECTION AGAINST DOMESTIC VIOLENCE________________________________________, Adverse Party.Please write or print clearly. Use black or dark blue ink. Complete this Application to the best of your knowledge. Applicant states the following facts under penalty of perjury:1. Applicant’s Date of Birth: _____________ Adverse Party’s Date of Birth: ___________Relationship: I am the __________________(for example, wife, ex-husband, girlfriend, father, sister, etc.) of the Adverse Party.(a) Length of relationship: _____________________. (b) Have you ever lived together? Yes No If so, how long? _____________ (c) Are you living together now? Yes No (d)Date of Separation: __________________________. (e)We have child(ren) TOGETHER: Yes or No If yes, where and with whom are these child(ren) living? _____________________________________ 2. My address is: CONFIDENTIAL . (If confidential, do not write address here) If address is not confidential, write below: Address__________________________________________________________________City______________________________ State__________ Zip Code_________________I own rent this residence. Lease/title is held in all the following name(s): _________________________________________________________________________How long have you been living in this residence? _________________________________. 2 1 23 4 56789 1011 12 13141516171819202122232425262728 3. Adverse Party’s address is: Address________________________________________________________________City______________________________ State_________ Zip Code________________How long has the Adverse Party been living in this residence?_____________________.4.My place of employment is CONFIDENTIAL. (If confidential, do not write address here) If not confidential, state place(s) of employment: Name of employer_________________________________________________________Address: _________________________________________Phone__________________City _____________________________ County ____________________State________Name of employer_________________________________________________________Address: _________________________________________Phone__________________City _____________________________ County ____________________State________Name of employer_________________________________________________________Address: _________________________________________Phone__________________City _____________________________ County ____________________State________5.Adverse Party’s employer is:________________________________________________Address: ________________________________________________Phone __________ City _____________________________County ____________________State________6.(a) The name(s) and date(s) of birth of the minor child(ren) of whom I am the parent, appointed guardian, or who live in my home, are as follows:NAME (first and last)DATE OF BIRTHAPPLICANT’S CHILD (Yes/No) ADVERSE PARTY’SCHILD (Yes/No) WHO CHILDLIVES WITH 1.Circle one Yes No Circle one Yes No 2.Circle one Yes No Circle one Yes No 3 1 23 4 56789 1011 12 13141516171819202122232425262728 NAME (first and last)DATE OF BIRTHAPPLICANT’S CHILD (Yes/No) ADVERSE PARTY’SCHILD (Yes/No) WHO CHILDLIVES WITH 3.Circle one Yes No Circle one Yes No 4.Circle one Yes No Circle one Yes No 5.Circle oneYes NoCircle oneYes No6.Circle oneYes NoCircle oneYes No(b) Have you or the Adverse Party ever been awarded custody/guardianship of the minor child(ren) by Court Order? Yes No Who was awarded custody/guardianship? Applicant Adverse Party By what Court? __________________________________________________________ Court Case No. (if known) __________________________________________________7. Please check the appropriate box, IF YOU or the ADVERSE PARTY have ever filed a case in any court for a Divorce, Custody, Paternity, Child Support, Guardianship, Order for Protection Against Domestic Violence, or Stalking/Harassment Order. Please indicate when and where the case(s) was filed, and list the case number(s) if known. ______________________________________________________________________________ ______________________________________________________________________________. 8.(a) Has CHILD PROTECTIVE SERVICES (CPS) ever been contacted regarding any member of the household in the past year? Yes No (b) Is CPS currently involved with your family? Yes No If yes, give details, including the caseworker’s name: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________. 4 1 23 4 56789 1011 12 13141516171819202122232425262728 9. (a) Does the Adverse Party possess a firearm, or does the Adverse Party have a firearm under his or her custody or control? Yes No I don’t know (b) Has the Adverse Party ever threatened, harassed, or injured you, the minor child(ren), or anyone else with a firearm or any other weapon? Yes No I don’t knowIf yes, give details: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________. 10.(a) I have been or reasonably believe I will become a victim of domestic violence committed by the Adverse Party. (b) The child(ren) have been or are in danger of becoming a victim of domestic violence committed by the Adverse Party. In the following space, state the facts that support your Application. Be as specific as you can, starting with the most recent incident. Include the approximate dates and locations, and whether law enforcement or medical personnel have been involved. THIS APPLICATION IS A PUBLIC RECORD ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 5 1 23 4 56789 1011 12 13141516171819202122232425262728 ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ PLEASE DO NOT WRITE ON THE BACKS OF ANY PAGES. 6 1 23 4 56789 1011 12 13141516171819202122232425262728 11. Have YOU ever been arrested or charged with domestic violence, or any other crime committed against your spouse, partner, or child(ren)? Yes No If yes, WHEN and where? ______________________________________________________________________________ ______________________________________________________________________________.12. To your knowledge, has the ADVERSE PARTY ever been arrested or charged with domestic violence, or any other crime committed against his/her spouse, partner, or child(ren)? Yes No I don’t know If yes, WHEN and where? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________. 13.An emergency exists, and I need a TEMPORARY ORDER FOR PROTECTION AGAINST DOMESTIC VIOLENCE issued immediately, without notice to the Adverse Party, to avoid irreparable injury or harm. I request that it include the following relief, and any other relief the Court deems necessary in an emergency situation. (Please check all the choice(s) that may apply to YOU): (A)Prohibit the Adverse Party, either directly or through an agent, from threatening, physically injuring, or harassing me and/or the minor child(ren).(B)Prohibit the Adverse Party from any contact with me whatsoever.(C)Exclude the Adverse Party from my residence and order the Adverse Party to stay at least 100 yards away from my residence.(D)Obtain law enforcement assistance to accompany me to the following residence, ___________________________________________________________________or to accompany the Adverse Party to the following residence, _____________________________________________________________________ to obtain personal property. (E)Grant temporary custody of the minor child(ren) to me.(F)Order that custody, visitation, and support of the minor child(ren) remain as ordered in the Decree of Divorce/Order entered in Case Number _______________________ in the ________________________________Court of the State of ______________________ . 7 1 23 4 56789 1011 12 13141516171819202122232425262728 (G) Order the Adverse Party to stay at least 100 yards away from the minor child(ren)’s school(s), or day care(s), located at CONFIDENTIAL (If confidential, do not write name of a school/day care and address here.) If NOT confidential, write name of school(s)/day care(s) and address(es) below: (1) Name of school or day care____________________________________________Address______________________________________________________________City ________________________ County ____________________ State _________(2) Name of school or day care____________________________________________Address______________________________________________________________City ________________________ County ____________________ State _________(3) Name of school or day care____________________________________________ Address______________________________________________________________City ________________________ County ____________________ State _________ (H)Order the Adverse Party to stay at least 100 yards away from my place(s) of employment. (I) Order the Adverse Party to stay at least 100 yards away from the following places, which I or the minor child(ren) frequent regularly: (1) Name _____________________________________________________________Address______________________________________________________________City ________________________ County ____________________ State _________(2) Name ____________________________________________________________Address______________________________________________________________City ________________________ County ____________________ State _________(3) Name_____________________________________________________________ Address______________________________________________________________City ________________________ County ____________________ State _________ 8 1 23 4 56789 1011 12 13141516171819202122232425262728 (J) (1) Prohibit the Adverse Party, either directly or through an agent, from physically injuring or threatening to injure any animal that is owned or kept by the Adverse Party, the minor child(ren), or me. (2) Prohibit the Adverse Party, either directly or through an agent, from taking possession of any animal owned or kept by me or the minor child(ren). (K) I further request the following other conditions: ______________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ __________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________. IF YOU WISH TO APPLY FOR A HEARING FOR AN EXTENDED ORDER FOR PROTECTION COMPLETE THE FOLLOWING INFORMATION14. I request the Court hold a hearing for an EXTENDED ORDER FOR PROTECTION AGAINST DOMESTIC VIOLENCE (which could be in effect for up to one year), and at that hearing the Court issue an Extended Order for Protection Against Domestic Violence and that it include the following relief and any other relief the Court deems appropriate. (Please check all the choice(s) that may apply to YOU). (A)Prohibit the Adverse Party, either directly or through an agent, from threatening, physically injuring, or harassing me and/or the minor child(ren).(B)Prohibit the Adverse Party from any contact with me whatsoever.(C)Exclude the Adverse Party from my residence and order the Adverse Party to stay at least 100 yards away from my residence. (D)Grant temporary custody of the minor child(ren) to me.(E)Grant the Adverse Party visitation with the minor child(ren).(F)Order the Adverse Party to pay support and maintenance of the minor child(ren). (You may be required to file an Affidavit of Financial Condition prior to the hearing). 9 1 23 4 56789 1011 12 13141516171819202122232425262728 (G) Order the Adverse Party to pay the rent or make payments on a mortgage or pay towards my support and maintenance.(H)Order that custody, visitation, and support of the minor child(ren) remain as ordered in the Decree of Divorce/Order entered in Case Number ____________in the __________________________________ Court of the State of ___________.(I)Order the Adverse Party to stay at least 100 yards away from the minor child(ren)’s school, or day care, located at: CONFIDENTIAL (If confidential, do not write name of school and address here). If address is not confidential, please write name of school or day care and address(es) below:(1) Name of school or day care_________________________________________Address: __________________________________________________________ City ____________________________ County _________________State _____ (2) Name of school or day care_________________________________________ Address___________________________________________________________ City ____________________________County _________________State______ 3) Name of school or day care_________________________________________ Address___________________________________________________________City ____________________________County _________________ State _____(J) Order the Adverse Party to stay at least 100 yards away from my place of employment. CONFIDENTIAL If address is not confidential, please write name of employer and address(es) below: (1) Name of Employer__________________________________________________Address: _____________________________________________________________City ____________________________ County _______________State___________ 10 1 23 4 56789 1011 12 13141516171819202122232425262728 (2) Name of Employer__________________________________________________ Address______________________________________________________________ City ____________________________County ________________State__________ (3) Name of Employer__________________________________________________ Address______________________________________________________________ City _____________________________County _______________State _________ (K) Order the Adverse Party to stay at least 100 yards away from the following places, which I or the minor child(ren) frequent regularly: (1) Name __________________________________________________________Address: __________________________________________________________ City __________________________County _______________State__________ (2) Name __________________________________________________________ Address___________________________________________________________ City __________________________County _______________State __________ (3) Name___________________________________________________________ Address___________________________________________________________ City __________________________County _____________State ____________(L) (1) Prohibit the Adverse Party, either directly or through an agent, from physicallyinjuring or threatening to injure any animal that is owned or kept by the Adverse Party, the minor child(ren), or me. (2) Prohibit the Adverse Party, either directly or through an agent, from taking possession of any animal owned or kept by me or the minor child(ren). (3) I request the Court to specify the arrangements for the possession and care of any animal owned or kept by the Adverse Party, the minor child(ren), or me. 11 1 23 4 56789 1011 12 13141516171819202122232425262728 (M) Order the Adverse Party to pay for lost earnings and expenses incurred as a result of my attendance at any hearing concerning this Application.(N) I further request the following other conditions: ____________________________________________________________________________________ ____________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________. I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF NEVADA THAT I HAVE READ THE STATEMENTS CONTAINED INTHIS APPLICATION, KNOW THE CONTENTS THEREOF, AND BELIEVE THEM TO BE TRUE AND CORRECT Dated: _____________ _________________________________________ Signature of Applicant _________________________________________ Applicant’s Name (Please Print)