Fillable DISTRICT COURT JUSTICE COURT IN THE TOWNSHIP OF (Family Law Self Help Center)

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DISTRICT COURT JUSTICE COURT IN THE TOWNSHIP OF (Family Law Self Help Center)

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© 2020 Nevada Supreme Court Uniform Child Custody Jurisdiction Enforcement Act Declaration
(DV Protection Order)
(Revised September 2020
)
Page 1 of 3
COURT CODE:
DISTRICT COURT
JUSTICE COURT IN THE TOWNSHIP OF
COUNTY, NEVADA
Applicant (print your name above),
vs.
Adverse Party (print the name of the
person you
want protection from above).
CASE NO.:
DEPT:
UCCJEA DECLARATION
*This document will be sealed and kept confidential if requested in section 9*
1.
Children.
Child 1:
First Middle Last DOB
Address City, State, Zip Code
When did the child start living here? (date)
Who does the child live with? Me Someone else (name)
Child 2:
First Middle Last DOB
Address City, State, Zip Code
When did the child start living here? (date)
Who does the child live with? Me Someone else (name)
Child 3:
First Middle Last DOB
Address City, State, Zip Code
When did the child start living here? (date)
Who does the child live with? Me Someone else (name)
Only fill out this form if you are asking for
children to be included in the protection order.
CLARK
© 2020 Nevada Supreme Court Uniform Child Custody Jurisdiction Enforcement Act Declaration
(DV Protection Order)
(Revised September 2020
)
Page 2 of 3
2.
Nevada Residence. How long have the children lived in Nevada? (☒ check one)
The children have lived in Nevada for the past six months, or since birth.
The children have NOT lived in Nevada for the past six months.
3.
Past Residences. List the other places the children have lived in the last 5 years.
Do not include where the children are living now.
Examples
Who the Child
Lived With
City & State Where
the Child Lived
Dates Child Lived
There (mo/yr – mo/yr)
Sue Jones (mom)
Las Vegas, NV
Past Residence:
Past Residence:
Past Residence:
If the children lived with anyone other than the parents in the last 5 years, write their
names and current addresses here:
4.
Department of Family Services (“DFS”) / Child Protective Services (“CPS”). Has
DFS / CPS been involved with your family? (☒ check one)
No.
Yes. When:
Caseworker’s name:
5.
Current Custody Case. Is there a custody order? (☒ check one)
No.
Yes, there is a current custody order concerning the child. The order is from case (case
number) . It was issued in (county)
County in the State of .
6.
Your Participation in Other Cases Concerning the Child. Have you participated in a
case concerning the child as a party, witness, or in some other capacity? (☒ check one)
No.
Yes, I have participated in the following cases concerning the child (list the state, the
court name, the case number and the date of the child custody order, if any):
© 2020 Nevada Supreme Court Uniform Child Custody Jurisdiction Enforcement Act Declaration
(DV Protection Order)
(Revised September 2020
)
Page 3 of 3
7.
Your Knowledge of Other Cases that You Did Not Participate In. Do you know of
any other case concerning the child that could affect this case, such as other custody
cases, protection order cases, or adoptions/terminations? (☒ check one)
No.
Yes, the following cases that could affect this case (list the state, the court name, the
parties involved, the case number and the type of case):
8.
Persons Other Than You or the Other Party Who Can Claim Custody / Visitation.
Is there anyone other than you or the adverse party who has custody of the child or who
can claim a right to custody or visitation with the child? (☒ check one)
No.
Yes, the following people have custody or can claim custody/visitation of the child:
(list names and addresses of anyone who claims custody/visitation rights):
9.
Confidentiality. Would your health/safety/liberty or the child’s health/safety/liberty be in
danger if the information in this document is released to the adverse party? (☒ check one)
Yes. This document should be sealed pursuant to NRS 125A.385(5). Note: the court
may release this information to the other party after a hearing if the court orders
the disclosure.
No. This document may be provided to the adverse party.
10.
This document does not contain the personal information of any person as defined by
NRS 603A.040.
I declare under penalty of perjury under the law of the State of Nevada that the
foregoing is true and correct.
DATED , 20 .
Submitted By: (your signature)
(print your name)
/s/
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DISTRICT COURT JUSTICE COURT IN THE TOWNSHIP OF (Family Law Self Help Center)

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Completed 15 January 2021

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