Nevada Temporary Order

APPLICATION FOR A TEMPORARY AND/OR EXTENDED ORDER FOR PROTECTION AGAINST DOMESTIC VIOLENCE

Case No. Dept. No.

IN THE JUSTICE COURT OF TOWNSHIP

COUNTY OF , STATE OF NEVADA

  Applicant APPLICATION FOR A TEMPORARY AND/OR EXTENDED ORDER FOR PROTECTION AGAINST DOMESTIC VIOLENCE

vs.  

  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 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 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? .

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:

(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.

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:

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 know

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

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 .

(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 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

(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 INFORMATION

14. 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).

(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 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

(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 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).

(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.

(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 IN THIS APPLICATION, KNOW THE CONTENTS THEREOF, AND BELIEVE THEM TO BE TRUE AND CORRECT