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DISTRICT COURT (print your name above), (Family Law Self Help Center)

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© 2020 Nevada Supreme Court
Ap
plication for Protection Order Against Domestic Violence
(Revised
September
2020)
Page 1 of 8
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: ____________________
APPLICATION FOR PROTECTION ORDER AGAINST DOMESTIC
VIOLENCE
1. Your information. (you are the “Applicant”)
2. Who do you want protection from? (this person is the “Adverse Party”)
Name: __________________________________________________________________
(first) (middle) (last)
Is this person currently in jail or prison? No Yes: (where?) ___________________
3. Who needs protection? ( check one or both)
Me.
The minor child(ren) below. (fill out the chart below and a UCCJEA Declaration,
available at http://selfhelp.nvcourts.gov/)
Child’s Name Date of Birth Parents
Parent 1: ____________________
Parent 2: ____________________
Parent 1: ____________________
Parent 2: ____________________
Parent 1: ____________________
Parent 2: ____________________
Parent 1: ____________________
Parent 2: ____________________
Your name: _______________________________________________________________
last) (first) (middle)
Interpreter Needed? No Yes: (language?) ___________________
CLARK
© 2020 Nevada Supreme Court
Application for Protection Order Against Domestic Violence
(Revised September 2020)
Page 2 of 8
4. Why do you need protection from the person named above? ( check all that apply)
The adverse party committed an act of domestic violence against me or has
threatened to commit an act of domestic violence against me.
The adverse party committed an act of domestic violence against a minor child or has
threatened to commit an act of domestic violence against the child.
I am the child’s parent or legal guardian.
5. How are you related to the person you want protection from? ( check all that apply)
We are married or used to be married.
We are dating or used to date.
We have children together.
Other: The adverse party is my (specify relationship): _________________________.
6. Are there any other court cases that involve you and the adverse party?
No.
Yes. If you know, list the case type, county, state, and case number:
7. Firearms / Guns. Does the adverse party own a gun or have a gun in his/her possession or
control? No Yes I don’t know
If you request an extended order, there will be a hearing where the judge may order the
other person to surrender, sell, or transfer any firearm, and may prohibit the other
person from having a gun. If the other person needs a gun for work, he / she may be
allowed to possess a firearm while on duty. This will be discussed at the hearing for an
extended order.
You must be a current/former intimate partner, or be related by blood, adoption, or
marriage, or be the parent or guardian of the adverse party’s child to apply for a
domestic violence protection order.
*Do not use this form if you want protection from an adult sibling or an adult cousin.
Adult siblings and cousins do not qualify to get a domestic violence protection order.
You may be able to apply for a different kind of protection order.
© 2020 Nevada Supreme Court Application for Protection Order Against Domestic Violence
(Revised September 2020)
Page 3 of 8
8. Most Recent Threat / Abuse / Incident.
Think about the most recent incident. These questions ask about the most recent incident
only.
Approximate date it happened:
City / State / Location where it happened:
Did the other person use or threaten to use a weapon? (a weapon can be a gun, a knife, or
any object that is used to cause or threaten physical harm)?
No.
Yes. (describe what kind of weapon was used or threatened)
Did the police come? No Yes
Was anyone arrested? No Yes (who?) ___________________________________
What Happened? Explain the most recent event and describe any injuries. Give specific
and detailed information about the event. You can list past events on the next page. If you
are filing on behalf of a child, include details about what happened to the child.
Attach more pages if you need more room. (Pages 3a, 3b, 3c)
© 2020 Nevada Supreme Court Application for Protection Order Against Domestic Violence
(Revised September 2020)
Page 4 of 8
9. Past Threats / Abuse / Incident.
Think about any other times the person you want protection committed an act of domestic
violence against you and/or the children. The following questions ask about any past
incidents that may have happened.
Has there been abuse or threats of violence in the past?
No (skip to the next page)
Yes (complete the sections on this page)
Approximate Date: _____________________
What Happened?
Attach more pages if you need more room. (Pages 4a, 4b, 4c)
Approximate Date: _____________________
What Happened?
Attach more pages if you need more room. (Pages 4a, 4b, 4c)
© 2020 Nevada Supreme Court
Application for Protection Order Against Domestic Violence
(Revised September 2020)
Page 5 of 8
10. Temporary Protections Requested. ( check all that apply)
Prohibited Activities. The adverse party should not threaten, physically injure, or
harass me and/or the minor child(ren), either directly or through someone acting on
his/her behalf.
Contact with You. The adverse party should:
Not contact me at all, either in person, by phone/text, by email, or through
social media.
Contact me to discuss parenting issues only by: text email
phone calls in writing other: ________
Contact with Children. The adverse party should:
Not contact the minor children at all, either in person, by phone/text, by
email, or through social media.
Contact the children by: text email phone calls in writing
other: __________
Current Residence. The adverse party should stay away from my current residence.
Do you and the adverse party live together? No Yes
If yes, whose name is listed on the lease/title? ____________________________
If yes, when did you start living together? ________________________________
Does the adverse party know where you live? No Yes
If no, is your address confidential? No Yes (don’t list your address)
_________________________________________
Address
_________________________________________
City, State, Zip Code County
This is a: temporary address permanent address
Do you and the adverse party live in the same complex/property/trailer park?
No. Should the Adverse Party stay away from the entire complex / property
/ trailer park? No Yes
Yes. Explain the distance and need for protection in that complex / property
/ trailer park:
Do not list any confidential addresses.
The other person will get a copy of this application and will see any
addresses you write down.
© 2020 Nevada Supreme Court
Application for Protection Order Against Domestic Violence
(Revised September 2020)
Page 6 of 8
Personal Belongings.
I need to get my belongings. I want law enforcement to come with me to the
adverse party’s residence so I can pick up my belongings. The address I need
to go to is (list street address, apartment number, city, state, zip):
______________________________________________________________.
The other person needs to get their belongings. Law enforcement should come
with the adverse party to my residence to pick up their belongings.
Work. The adverse party should stay away from my workplace.
Do you and the adverse party work at the same place? No Yes
Is your work address confidential? No Yes (do not write details below)
Employer
Address
City, State, Zip Code County
Employer
Address
City, State, Zip Code County
School / Day Care. The adverse party should stay away from my school and/or the
child(ren)’s school/day care.
Is the school address confidential? No Yes (do not write details below)
School/Day Care Name
Address
City, State, Zip Code County
School/Day Care Name
Address
City, State, Zip Code County
Other Places. The adverse party should stay away from the following places that I
and/or the minor child(ren) go to regularly.
Location Name
Why?
Address
City, State, Zip Code County
Location Name
Why?
Address
City, State, Zip Code County
© 2020 Nevada Supreme Court
Application for Protection Order Against Domestic Violence
(Revised September 2020)
Page 7 of 8
Children / Custody Orders. I want temporary custody of the child(ren).
*you must complete a UCCJEA Declaration to give more information*
The adverse party should not have visitation at this time.
The adverse party should have visitation with the child(ren) as follows:
_____________________________________________________________.
We already have a custody/visitation order that we should keep following.
The order is from case (case number) ___________________. It was issued
in (county) _________________ County in the State of _______________.
Pets or Animals – Safety. The adverse party should be ordered not to threaten,
physically injure or harass any pets/animals kept by me, the children, or the adverse
party, either directly or through someone acting on his/her behalf.
Pets or Animals – Possession. I want to keep the pets/animals. The adverse party
should be prohibited from taking the pets/animals either directly or through someone
acting on his/her behalf.
11. Length of Protection Order.
I want an order up to 45-days only. Stop here and sign the next page.
I want an order up to 45-days PLUS an extended order that could last up to 2
years. The extended order should require the adverse party to do the following in
addition to the temporary requests I already asked for:
*You may have to fill out and file a financial form if you want the judge
to grant you any kind of financial support.
*Pay rent or mortgage payments for my place of residence.
*Pay emergency household support for me.
*Pay child support for the minor child(ren) we have together.
*Pay for lost earnings and expenses incurred as a result of my attendance
at any hearing concerning this application.
*Pay any costs and fees I have spent in pursuing this case.
This application automatically asks the judge to issue up to a 45 day temporary protection
order without notifying the other person first. You will get a decision within 1 business day.
You can also ask for an extended order that could last for up to 2 years.
If you do, the judge will set a hearing. You and the other person will have to appear in
court and explain your side before the judge can extend the protection order.
© 2020 Nevada Supreme Court
Application for Protection Order Against Domestic Violence
(Revised September 2020)
Page 8 of 8
The judge should make the following long-term arrangement for the
pets/animals owned by myself, the child(ren), and/or the adverse party
(describe the pets/animals involved and who should take care of the
pets/animals while an extended order is in effect)
Other:
12. UCCJEA Declaration. If you want the judge to grant you temporary custody of a child,
fill out a UCCJEA Declaration and file it with this application.
13. You may attach documents, pictures, or anything else that you would like the judge to look
at and consider when reviewing your application. The Adverse Party will receive a copy of
all documents/evidence you provide.
Describe what you are attaching:
14. 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)
VERIFICATION
I declare that I am the Applicant in the above-entitled action; that I have read the
foregoing application and know the contents thereof; that the pleading is true of my own
knowledge, except for those matters therein contained stated upon information and belief, and
that as to those matters, I believe them to be true.
I declare under penalty of perjury under the law of the State of Nevada that the
foregoing is true and correct.
Submitted by: (your signature)
(print your name)
/s/
/s/
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Completed 15 January 2021

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