Fillable Form 1: 2 3 4 Applicant, 5 vs. (Supreme Court of Nevada)

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Form 1: 2 3 4 Applicant, 5 vs. (Supreme Court of Nevada)

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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? _________________________________.
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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
BIRTH
APPLICANT’S
CHILD (Yes/No)
ADVERSE
PARTY’S
CHILD (Yes/No)
WHO
CHILD
LIVES
WITH
1.
Select one
Yes No
Select one
Yes No
2.
Select one
Yes No
Select one
Yes No
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NAME (first and last)
DATE
OF
BIRTH
APPLICANT’S
CHILD (Yes/No)
ADVERSE
PARTY’S
CHILD (Yes/No)
WHO
CHILD
LIVES
WITH
3.
Select one
Yes No
Select one
Yes No
4.
Select one
Yes No
Select one
Yes No
5.
Select one
Yes No
Select one
Yes No
6.
Select one
Yes No
Select one
Yes 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:
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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
If 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
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PLEASE DO NOT WRITE ON THE BACKS OF ANY PAGES.
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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 ______________________ .
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(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 _________
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(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). (You
may be required to file an Affidavit of Financial Condition prior to the hearing).
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(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___________
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(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.
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(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
Dated: _____________
_________________________________________
Signature of Applicant
_________________________________________
Applicant’s Name (Please Print)
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Form 1: 2 3 4 Applicant, 5 vs. (Supreme Court of Nevada)

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Completed 15 August 2020

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