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1 CHILD
Case Number: _________________________
(to be assigned by the Clerk’s Office)
Nevada AOC – Research & Statistics Unit Revised 03/2019
Pursuant to NRS 3.275
CLARK COUNTY, NEVADA
FAMILY COURT COVER SHEET
PARTIES:
Plaintiff/Petitioner Defendant/Respondent/Co-Petitioner/Protected Person
Last Name: Last Name:
First Name: Middle Name: First Name: Middle Name:
Mailing Address: Mailing Address:
City, State, Zip: City, State, Zip:
Phone #: Date of Birth: Phone #: Date of Birth:
Email Address: Email Address:
Attorney Information not applicable Attorney Information not applicable
Name: Bar No. Name: Bar No:
Address: Address:
City, State, Zip: City, State, Zip:
Phone #: Phone #:
CASE TYPE: (Check only one box only for the primary type of case you are filing)
DISSOLUTION
MISC. DOMESTIC RELATIONS
PETITIONS
GUARDIANSHIP OTHER
Annulment
Divorce –No minor child(ren)
Divorce –With minor child(ren)
Foreign Decree
Joint Petition –No minor child(ren)
Joint Petition – With minor child(ren)
Separate Maintenance
Adoption –Minor
Adoption –Adult
Child Custody (non-divorce)
Child Support (private party)
Mental Health
Name Change
Paternity
Permission to Marry
Temporary Protective Order (TPO)
Termination of Parental Rights
(private party)
Termination of Parental Rights
(State initiated)
Visitation (non-divorce)
Other (identify) __________________
Guardianship of an Adult
Person
Estate
Person and Estate
Guardianship of a Minor
Person
Estate
Person and Estate
Guardianship Trust
DA Child Support
DA – UIFSA
DA – Child Support In State
DA Child Dependency
DA – Abuse/Neglect
DA – No Fault
DA – Other (identify)
__________________
Juvenile
Emancipation
CHILDREN INVOLVED IN THIS CASE (if applicable)
Last Name First Name Middle Name Date of Birth Relationship
1.
2.
3.
4.
5.
6.
7.
8.
Does this family have any other current or past case(s) in the Clark County Family Court or Juvenile Court?
YES NO
_________________________________ __________________________________ ________________
Your Printed Name Your Signature Date
/s/
© 2018 Nevada Supreme Court
Page 1 of 2 – Confidential Information Sheet (Child)
COURT CODE: CISG
Your Name:
Address:
City, State, Zip:
Telephone:
Email Address:
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Guardianship of the:
Person
Estate
Person and Estate
of:
_
___________________________________
(name of child who needs a guardian)
A Proposed Protected Minor.
CASE NO.: ____________________
DEPT: ____________________
CONFIDENTIAL INFORMATION SHEET – GUARDIANSHIP
First Guardian (full legal name): __________________________________________________
Identification Attached (check one and attach a copy):
Social Security Number
Birth Certificate
Valid Driver’s License Number
Valid Identification Card
Number
Valid Passport Number
Second Guardian (full legal name, or “n/a” if none): ___________________________________
Identification Attached (check one and attach a copy):
Social Security Number
Birth Certificate
Valid Driver’s License Number
Valid Identification Card
Number
Valid Passport Number
Child (child’s full legal name): ________________________________________
Identification Attached (check one and attach a copy):
Social Security Number
Birth Certificate
Valid Driver’s License Number
Valid Identification Card
Number
Valid Passport Number
© 2018 Nevada Supreme Court
Page 2 of 2 – Confidential Information Sheet (Child)
Placement Of Child: Location Of Guardian(s):
With Guardian
Secured Facility
Group Home
Host Family
Family/Friends
Out of State
Other
Nevada
Other State (list): _____________________
Proposed Guardian(s) Relationship to the
Child:
Relative
Private: License Number: ___________
Other
Child’s Gender: Child’s Date Of Birth:
Male
Female
Date of Birth: _______________________
Date Child Turns 18: _________________
Submitted by:
(Attach copies of the identification indicated for each guardian and the child)
(Signature)
(Printed Name)
/s/
© 2018 Nevada Supreme Court
Page 1 of 14 – Petition for Appointment of Guardian Including Temporary Guardianship (Child)
COURT CODE: PTGD
Your Name:
Address:
City, State, Zip:
Telephone:
Email Address:
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Guardianship of the:
Person
Estate
Person and Estate
of:
_
___________________________________
(name of child who needs a guardian)
A Proposed Protected Minor.
CASE NO.: ____________________
DEPT: ____________________
PETITION FOR APPOINTMENT OF GUARDIAN(S) OVER CHILD
INCLUDING REQUEST FOR TEMPORARY GUARDIANSHIP
Petitioner (proposed guardian’s name) _______________________________________
and Co-Petitioner (proposed co-guardian’s name; if only one guardian, write “N/A”)
____________________________________ would like to be appointed the Guardian(s) over
the above-named child. In accordance with 2017 Nevada Laws Ch. 172 (A.B. 319),
Petitioner(s) respectfully represents the following to this Honorable Court:
Petitioner’s Information (the first proposed guardian)
1. Full legal name: ______________________________________________________.
2. Date of birth: ___________________________.
3. Relationship to child in need of a guardian: _____________________________________.
Page 2 of 14 – Petition for Appointment of Guardian Including Temporary Guardianship (Child)
4. Residence address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
Mailing address (if different than residence address):
_________________________________________
Address
_________________________________________
City, State, Zip Code
5. Qualifications. (Answer each item listed; “Has” answers must be explained)
The Petitioner: (☒ check one for each)
has has not been convicted of a crime of moral turpitude, a crime involving
domestic violence or a crime involving the abuse, neglect,
exploitation, isolation or abandonment of a child, his or her spouse,
his or her parent or any other adult.
Explain if Yes: ___________________________________________
________________________________________________________
has has never been convicted of a felony.
Explain if Yes: Petitioner was convicted of (describe conviction)
________________________________________________________
Petitioner ( check one) □ was / □ was not placed on parole and (
check one) □ was / □ was not placed on probation for that felony.
has has not filed for bankruptcy within the past 7 years.
is is not a party to pending criminal or civil litigation.
Explain if Yes: ___________________________________________
________________________________________________________
Page 3 of 14 – Petition for Appointment of Guardian Including Temporary Guardianship (Child)
Co-Petitioner’s Information (the second proposed guardian)
Not Applicable (check if there is only one proposed guardian, and go to page 4)
6. Full legal name: ______________________________________________________.
7. Date of birth: ___________________________.
8. Relationship to child in need of a guardian: _____________________________________.
9. Residence address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
Mailing address (if different than residence address):
_________________________________________
Address
_________________________________________
City, State, Zip Code
10. Qualifications. (Answer each item listed; “Has” answers must be explained)
The Co-petitioner: (☒ check one for each)
has has not been convicted of a crime of moral turpitude, a crime involving
domestic violence or a crime involving the abuse, neglect,
exploitation, isolation or abandonment of a child, his or her spouse,
his or her parent or any other adult.
Explain if Yes: ___________________________________________
________________________________________________________
has has never been convicted of a felony.
Explain if Yes: The Petitioner was convicted of (describe conviction)
________________________________________________________
The Petitioner ( check one) □ was / □ was not placed on parole and
( check one) □ was / □ was not placed on probation for that felony.
has has not filed for bankruptcy within the past 7 years.
is is not a party to pending criminal or civil litigation.
Explain if Yes: ___________________________________________
________________________________________________________
Page 4 of 14 – Petition for Appointment of Guardian Including Temporary Guardianship (Child)
Child’s Information
11. Child’s full legal name: _____________________________________________________.
12. Child’s date of birth: ___________________________; current age: _______. The child
will become 18 years old on (date) ____________________.
13. Petitioner(s) believe the child ( check one) will / will not need a guardian when
the child turns 18 years old. If yes, explain why a guardian will still be needed:
________________________________________________________________________.
14. The child has been a resident of the State of (state) __________________________ since
(date) ________________________.
15. The child currently lives at the following address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
The child has lived at the above address since (date) ________________________.
16. The child has lived at the following places with the following people within the last 5
years (list the places the child has lived in the last 5 years):
Time Period (mo/yr
– mo/yr)
Name of Person the Child
Lived With:
City and State
i.e., 5/17-9/17 Sue Jones (grandma) Las Vegas, NV
________ - _______
________ - _______
________ - _______
________ - _______
________ - _______
The names and current addresses of each non-parent the child lived with during the last
five years are:
Page 5 of 14 – Petition for Appointment of Guardian Including Temporary Guardianship (Child)
17. Participation in Other Cases. Have you ever participated in any 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 (provide all
specifics including the state, the court name, the case number and the date of the child
custody order, if any):
18. Knowledge of Other Cases. Do you know of any other case that could affect this case,
such as other custody cases, domestic violence cases, protection order cases, or adoptions /
terminations? (☒ check one)
No.
Yes, the following cases that could affect this case (provide all specifics including the
state, the court name, the parties involved, the case number and the type of case):
19. Current Custody Case: Is there a custody order concerning the child? (☒ check one)
No.
Yes, there is a current order concerning custody of the child. The order is from the
State of _________________ and was filed on (date) _______________. If the order
was not registered with this Court, a copy of the order will be filed with this Petition.
20. Persons Who Can Claim Custody / Visitation. Is there anyone other than yourself or
other parties to this case 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):
Page 6 of 14 – Petition for Appointment of Guardian Including Temporary Guardianship (Child)
21. The child is currently under the care of (name and address of person caring for the child):
_________________________________________
Name
_________________________________________
Address
_________________________________________
City, State, Zip Code
The person above is caring for the child because (explain why the child is under the care
of the person above):
________________________________________________________________________
________________________________________________________________________
22. Does the child receive Medicaid, or has this child ever received Medicaid? (☒ check one)
No
Yes
23. Is the child a member of a federally recognized tribe? (☒ check one)
No
Yes, the tribe is (write tribe’s name) __________________________________
24. Is the child a citizen of another country? (☒ check one)
No
Yes, the child is a citizen of (write country name) __________________________
25. Is the child a party to any pending criminal or civil lawsuit? (☒ check one)
No
Yes (explain) _______________________________________________________
26. Are you seeking guardianship in order to initiate litigation? (☒ check one)
No
Yes (explain) _______________________________________________________
Page 7 of 14 – Petition for Appointment of Guardian Including Temporary Guardianship (Child)
Child’s First Parent
27. The first parent is (name) __________________________________________________.
( check if applicable)
This parent is deceased. *File a copy of the death certificate with this Petition.*
This parent’s parental rights over the child were terminated by a court order.
*File a copy of the termination order with this Petition.*
28. This parent currently lives at the following address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
Mailing address (if different than residence address):
_________________________________________
Address
_________________________________________
City, State, Zip Code
29. Consent ( check one):
This parent agrees to this proposed guardianship and will file a proper notarized
consent.
This parent does not consent to the proposed guardianship, or cannot be located to
consent.
30. This parent is unable to care for the child because (explain):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Page 8 of 14 – Petition for Appointment of Guardian Including Temporary Guardianship (Child)
Child’s Second Parent
31. The second parent is (name) _________________________________________________.
( check if applicable):
This parent is deceased. *File a copy of the death certificate with this Petition.*
This parent’s parental rights over the child were terminated by a court order.
*File a copy of the termination order with this Petition.*
This parent is an unknown father. There is no father listed on the child’s birth
certificate. There has never been a court order regarding child support, custody, or a
finding of paternity.
32. This parent currently lives at the following address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
Mailing address (if different than residence address):
_________________________________________
Address
_________________________________________
City, State, Zip Code
33. Consent ( check one):
This parent agrees to this proposed guardianship and will file a proper notarized
consent.
This parent does not consent to the proposed guardianship, or cannot be located to
consent.
34. This parent is unable to care for the child because (explain):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Page 9 of 14 – Petition for Appointment of Guardian Including Temporary Guardianship (Child)
Temporary Guardianship Request
35. The proposed guardian(s) request to be appointed the temporary guardian(s) over the
above-named child because (explain why the Court should appoint a temporary guardian
now before a court date):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
36. Parent Involvement. ( check one)
During the last six months, a parent has had the child in their care, custody, or
control.
During the last six months, neither parent has had the child in their care, custody, or
control. The child has been living with: (name and relationship of all the people
the child has been living with)
___________________________________________________________________
_________________________________________________________________.
If no parent of a proposed protected minor has had the care, custody and control of
the minor for the 6 months immediately preceding the petition, temporary
guardianship is presumed to be in the minor’s best interest, in accordance with
Assemb. B. 319, 2017 Leg., 79
th
Sess. (Nev. 2017).
37. Medical Needs. ( check one)
The child does not need immediate medical attention.
The child needs immediate medical attention.
*You must file the following if the child needs immediate medical attention:
Documentation that shows the child’s immediate medical needs, and
proof that the child cannot get medical attention without this temporary
guardianship;
A copy of the child’s birth certificate, or some other documentation that
verifies the child’s age.
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f your
Page 11 of 14 – Petition for Appointment of Guardian Including Temporary Guardianship (Child)
I did not notify the following relatives about the temporary guardianship because
the child would be at immediate risk of physical, emotional and/or financial
harm if notice was provided before the court determines whether to appoint the
temporary guardian: (list the people you did not notify because it would put the
child in danger)
Name of Person Not
Notified
Reason You Did Not Notify
**You must notify the people above within 48 hours if you are appointed a
temporary guardian.**
I have not notified the following relatives about the temporary guardianship because
it is not feasible/practical to notify them at this time: (list any relatives you did
not notify because you cannot or do not know where to find them)
Name of Person Not
Notified
Reason You Did Not Notify
**If you find the people above, you must notify them within 48 hours of finding
them. If you can’t find them, you will need to request the judge’s permission to
waive service on these people, or to serve them by publishing a notice in a
newspaper instead.**
Page 12 of 14 – Petition for Appointment of Guardian Including Temporary Guardianship (Child)
39. I understand that if I am appointed a temporary guardian:
The court will set a hearing within 10 days to decide whether to extend the
temporary guardianship.
I will have to attempt in good faith to notify the child’s relatives and any other
required person of the temporary guardianship and the hearing to extend the
temporary guardianship. If I do not, the court can terminate the guardianship.
The court can extend the temporary guardianship only if there is clear and
convincing evidence that the child still needs a temporary guardian. If extended,
the guardianship usually can only be extended for two 60-day periods.
General Information
40. Reason for Permanent Guardianship. A long-term guardianship is needed for the child
because (explain why you need to be the guardian after the emergency is over):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________.
41. The child’s parent or legal guardian ( check one) has / has not nominated a
guardian in writing. The nominated guardian is (name) ___________________________.
42. Abuse/Neglect Report: ( check one)
The guardianship IS NOT requested because of an investigation of abuse or neglect
conducted by Child Protective Services (CPS) or law enforcement.
The guardianship IS requested because of an investigation by Child Protective
Services (CPS) or other similar agency. The investigating agency is (name of
agency) ________________________________________. The caseworker’s name
is (caseworker name) _____________________________________________. The
investigating agency ( check one) does / does not approve of this
guardianship and the placement of the child with the proposed Guardians.
Page 13 of 14 – Petition for Appointment of Guardian Including Temporary Guardianship (Child)
43. Compensation. Are you currently being paid for services as a guardian to more than one
protected person who is not related to you by blood or marriage? ( check one):
No, I am not being paid for services as a guardian.
Yes, I am being paid for services as a guardian for (number) ______ children.
44. Petitioner(s) is/are competent and capable of acting as guardian of the above proposed
protected minor and hereby consents to act in this capacity.
45. Confidential Information Sheet – Guardianship must be completed and filed. You must
provide at least one form of identification (listed on the sheet) for each person.
46. Exhibit A: List of All of the Child’s Relatives must be completed and attached to this
petition.
47. Exhibit B: Information Regarding the Child’s Estate must be completed and attached to
this petition if you are requesting guardianship over the child’s estate. If you are appointed
the Guardian, the Court will determine how to safeguard the child’s funds. The Court will
decide whether to:
Require the funds to be placed into a blocked account.
Require you to obtain a bond in an amount equal to the total amount of the child’s
liquid assets.
48. Other Exhibits: If you have a letter from a governmental agency in this state which
conducts investigations, or a certificate signed by any other person whom the court finds
qualified to execute a certificate, the letter/certificate must be attached to this petition.
Petitioner requests that this guardianship be granted, that the relief requested be granted
as stated herein, and for such other and further relief as the Court may deem just and proper.
DATED (month) ________________________ (day) _______, 20___.
(Second Petitioner’s Signature)
(Printed Name)
(First Petitioner’s Signature)
(Printed Name)
/s/
/s/
Page 14 of 14 – Petition for Appointment of Guardian Including Temporary Guardianship (Child)
VERIFICATION
I, (name of first petitioner) ________________________________________, declare
that I am the Petitioner in the within action; that I have read the foregoing Petition For
Appointment of Guardians and know the contents thereof; that the same is true of my
knowledge except as to those matters therein stated upon information and belief and 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.
__________________________________________
FIRST PETITIONER’S SIGNATURE
VERIFICATION
I, (name of second petitioner) ________________________________________, declare
that I am the Co-Petitioner in the within action; that I have read the foregoing Petition For
Appointment of Guardians and know the contents thereof; that the same is true of my
knowledge except as to those matters therein stated upon information and belief and 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.
__________________________________________
SECOND PETITIONER’S SIGNATURE
/s/
/s/
EXHIBIT A: List All of the Child’s Relatives
Parent:
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Parent:
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Grandparents:
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Brothers and Sisters:
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown
EXHIBIT B: Information Regarding the Proposed Protected Minor’s Estate
Complete this page only if you are requesting guardianship over the estate.
1. The proposed protected minor ( check all that apply)
Has no assets or income
Has assets and income (list below)
Is entitled or will be entitled to assets or income (list below)
2. The proposed protected minor receives income from the following: (include all income,
including Social Security, Department of Veteran’s Affairs, pensions, etc. If none, write
“N/A”. If there are not enough lines below, write “SEE ATTACHED” and attach a page
with the additional income sources.) (check and answer all that apply)
Child Support Yes No monthly: $_______________________
Social Security Yes No monthly: $_______________________
Veterans Affairs Yes No monthly: $_______________________
a. __________________________________ monthly: $_______________________
b. __________________________________ monthly: $_______________________
3. Is there a Representative Payee receiving benefits on behalf of the proposed protected
minor? No Yes, the person is (name) ____________________________________.
4. The proposed protected minor assets are: (include all assets including checking / savings /
investment accounts, real estate, vehicles, inheritances, including insurance policies, etc. If
none, write “N/A”. If there are not enough lines below, write “SEE ATTACHED” and
attach a page containing the additional assets.)
a. __________________________________ value: $_______________________
b. __________________________________ value: $_______________________
c. __________________________________ value: $_______________________
d. __________________________________ value: $_______________________
e. __________________________________ value: $_______________________
f. __________________________________ value: $_______________________
g. __________________________________ value: $_______________________
h. __________________________________ value: $_______________________
i. __________________________________ value: $_______________________
You will be required to file a detailed Inventory listing all of the protected person’s assets
within 60 days of your appointment.
© 2018 Nevada Supreme Court
Page 1 of 2 – Declaration in Support of Request for Temporary Guardianship (Child)
COURT CODE: DECL
Your Name:
Address:
City, State, Zip:
Telephone:
Email Address:
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Guardianship of the:
Person
Estate
Person and Estate
of:
_
___________________________________
(name of child who needs a guardian)
A Proposed Protected Minor.
CASE NO.: ____________________
DEPT: ____________________
DECLARATION IN SUPPORT OF PETITION FOR APPOINTMENT OF
TEMPORARY GUARDIANSHIP
I/We, (first proposed guardian’s name) ____________________________________ and
(proposed second guardian’s name; or “N/A”) ______________________________________
request temporary guardianship over the child named in this petition. The child needs a
temporary guardian appointed immediately because (explain the emergency that you need to take
care of before a court date)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
© 2018 Nevada Supreme Court
Page 2 of 2 – Declaration in Support of Request for Temporary Guardianship (Child)
I/We request the Court to sign an Order granting temporary guardianship over the
proposed protected minor.
I/We declare under penalty of perjury under the law of the State of Nevada that the
foregoing is true and correct.
DATED (month) ________________________ (day) _______, 20___.
(Second Petitioner’s Signature)
(Printed Name)
(First Petitioner’s Signature)
(Printed Name)
/s/
/s/
© 2018 Nevada Supreme Court
Page 1 of 2 – Citation to Appear and Show Cause (Child)
COURT CODE: CIEI
Your Name:
Address:
City, State, Zip:
Telephone:
Email Address:
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Guardianship of the:
Person
Estate
Person and Estate
of:
_
___________________________________
(name of child who needs a guardian)
A Proposed Protected Minor.
CASE NO.: ____________________
DEPT: ____________________
CITATION TO APPEAR AND SHOW CAUSE
TO: (Child’s Name)
(Parent’s Name)
(Parent’s Name)
ALL OTHER KNOWN RELATIVES OF THE CHILD:
(Write each relative’s name on a separate line)
ANY PERSON HAVING THE CARE, CUSTODY, AND CONTROL OF THE CHILD
DIRECTOR OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES
Page 2 of 2 – Citation to Appear and Show Cause (Child)
PLEASE TAKE NOTICE that the following person(s) (proposed guardian’s name)
_____________________________________________ and (proposed co-guardian’s name)
_____________________________________________ petitioned the court to be appointed the
guardian(s) of the proposed protected minor. A guardian may be appointed for the proposed
protected minor at the hearing date noted below. The proposed guardian(s) may be awarded the
full management, care, and control of the proposed protected minor.
The rights of the proposed protected minor and of any person having legal or physical
custody of the proposed protected minor may be affected as specified in the petition.
The proposed protected minor has the right to appear at the hearing and to oppose the
petition.
The proposed protected minor has the right to be represented by an attorney.
At any time during proceedings on the citation, the court may appoint for the proposed
protected minor: (a) an attorney; (b) a guardian ad litem or an advocate for the best interests of
the proposed protected minor pursuant to 2017 Nevada Laws Ch. 172 (A.B. 319).
DATE AND TIME OF COURT APPEARANCE
(the court clerk will fill this out)
YOU ARE DIRECTED TO APPEAR AND SHOW CAUSE why a guardian should
not be appointed for the proposed protected minor on the:
_____ day of ____________________, 20____, at _______ □ a.m. □ p.m., at the courthouse of
the 8
th
Judicial District Court, in Courtroom number _____, located at
Regional Justice Center, 200 Lewis Avenue, Las Vegas, NV 89101
Family Court, 601 N. Pecos Rd., Las Vegas, NV 89101
DATED this _____ day of ___________________, 20___.
CLERK OF COURT
BY: ____________________________________
DEPUTY CLERK
NOTE: The child and the proposed guardian(s) must appear at the scheduled hearing; all other
interested parties do not need to appear unless they wish to oppose the guardianship and enter
an objection.
© 2018 Nevada Supreme Court
Page 1 of 3 – Order Appointing Temporary Guardian (Child)
COURT CODE: _____________________
Your Name:
Address:
City, State, Zip:
Telephone:
Email Address:
Self-Represented
DISTRICT COURT
_______________ COUNTY, NEVADA
In the Matter of the Guardianship of the:
Person
Estate
Person and Estate
of:
_
___________________________________
(name of child who needs a guardian)
A Protected Minor.
CASE NO.: ____________________
DEPT: ____________________
ORDER APPOINTING TEMPORARY GUARDIAN(S) OVER MINOR
DATE OF EXPIRATION:
______________
UPON REVIEW of the verified Petition for Appointment of Guardian(s) and
Declaration submitted by the Petitioners, the same having been reviewed by the Court, and there
being good cause to believe that a temporary guardianship is in the best interest of the minor
child:
THE COURT FINDS that the proposed protected minor child, (child’s name)
____________________________________, born on (date of birth) _____________________,
faces a substantial and immediate risk of financial loss or physical harm and/or needs immediate
medical attention or other necessities of life and will not be afforded such attention or
necessities unless this temporary guardianship is issued.
THE COURT FURTHER FINDS that the Court has jurisdiction to enter this order as the
proposed protected minor is a resident of the State of Nevada or has been placed in the State of
Nevada by a legal or authorized agent or agency acting on behalf of the minor.
CLARK
© 2018 Nevada Supreme Court
Page 2 of 3 – Order Appointing Temporary Guardian (Child)
THE COURT FURTHER FINDS that Petitioner(s) have made a good faith effort to
contact the parents of the proposed protected minor and/or any other person or agency having
the care, custody, and control of the minor, or, in the alternative, has/have presented evidence
that such contact would put the welfare of the minor in jeopardy or is impractical under the
circumstances.
THEREFORE, IT IS HEREBY ORDERED that (first guardian’s full name)
_____________________________________________ and Co-Petitioner (co-guardian’s
name; if only one guardian, write “N/A”) __________________________________________,
are appointed Temporary Guardian(s) of the above-named protected minor child.
IT IS FURTHER ORDERED that (court will check if applicable) the powers of the
Guardian(s) are limited to those necessary to respond to the protected minor’s need for
immediate medical attention.
NOTICE OF HEARING FOR EXTENSION OF TEMPORARY GUARDIANSHIP
PLEASE TAKE NOTICE that the court will determine whether to extend this temporary
guardianship at a hearing on the (the court will fill in a hearing date) _____ day of
_________________, 20____, at _______ a.m. p.m., in Courtroom _____ located at
(court address) _____________________________________________________________
IT IS FURTHER ORDERED that Temporary Letters of Guardianship shall issue to the
Guardian(s) upon the taking of the oath of office as required by law.
IT IS FURTHER ORDERED that this Order shall automatically terminate and have no
further force and effect after the hearing set forth above. If the court finds by clear and
convincing evidence that the protected minor continues to be in need of a temporary guardian,
the court may extend the guardianship until a general guardian is appointed pursuant to Assemb.
B. 319, 2017 Leg., 79
th
Sess. (Nev. 2017).
IT IS FURTHER ORDERED that the Temporary Guardian(s) shall attempt in good faith
to notify the persons entitled to notice regarding this temporary guardianship and the hearing set
forth above.
NOTICE IS HEREBY GIVEN that if the court determined that advance notice was not
© 2018 Nevada Supreme Court
Page 3 of 3 – Order Appointing Temporary Guardian (Child)
required because the protected minor would have been exposed to an immediate risk of
physical, emotional and/or financial harm had the Guardian(s) provided notice, the Guardian(s)
shall notify the persons entitled to notice without undue delay, but not later than 48 hours after
the appointment of a temporary guardian or not later than 48 hours after he/she discovers the
existence, identity and location of the persons entitled to notice. If the Guardian(s) fail(s) to
provide such notice, the court may terminate the temporary guardianship.
DATED this _____ day of ______________________, 20___.
Respectfully Submitted by:
DISTRICT COURT JUDGE
(Your Signature)
(Printed Name)
/s/
This page explains what you need to do to get your Emergency Guardianship Order.
Mail: Send your forms to Clerk of Court, 601 N Pecos, Las Vegas, NV 89101.
Online: You can upload your documents at https://nevada.tylerhost.net/OfsWeb/. There is a $3.50
fee to e-file your documents. The Order Appointing Temporary Guardian should not be
efiled, but it can be emailed after you efile the other forms. See Step 2 for more information.
You can submit in one of the ways below. The judge’s staff will notify you of the judge’s decision
.
Mail it to the courthouse: Mail it to: Family Court, 601 N. Pecos Rd., Las Vegas, NV 89101
Email it to your judge: Find the letter that your case is assigned to (for example, Dept C, Dept
F, etc.). Insert the department letter where the _ is in the following email format:
dept_inbox@clarkcountycourts.us and send it by email.
You will have to show the judge you have started to notify people of your case. You must serve:
o The child’s parents.
o All the relatives age 14 and older listed on Exhibit A, including grandparents on
both sides and siblings.
o Medicaid (if the child receives Medicaid – address is provided on the form)
To prove they have been notified, you can either:
Get written consents. Any relative can sign and notarize a
consent
agreeing to make you
the guardian. If the child is 14 or older, the child must consent in writing. SHC has the forms.
Send the Petition and Citation by certified mail, return receipt requested. For
relatives who won’t consent, send them a copy of the filed Petition and the Citation by
certified mail, return receipt requested
. Use the “green cards” at the post office.
YOU MUST SERVE ALL OF THE PEOPLE LISTED ABOVE; NO EXCEPTIONS!
If you don’t know how to contact someone, visit https://www.familylawselfhelpcenter.org/self-
help/guardianship/filing-for-guardianship-over-a-child/court-ordered-child-guardianship/223-
serve for other options.
Complete the Temporary Letters of Guardianship and file them. This is what gives you
the power to act as the temporary guardian.
Check the Order for the court date and plan to attend the hearing. The court date is on
page 3. Notify the relatives of the court date since they are allowed to attend. At the hearing,
the judge may extend your temporary guardianship or may end it if the emergency is over.
© 2018 Nevada Supreme Court
Page 1 of 2 – Temporary Letters of Guardianship (Child)
COURT CODE: _____________________
Your Name:
Address:
City, State, Zip:
Telephone:
Email Address:
Self-Represented
DISTRICT COURT
_______________ COUNTY, NEVADA
In the Matter of the:
Temporary Guardianship of the Person
Temporary Guardianship of the Estate
Temporary Guardianship of the Person
& Estate
Temporary Special Guardianship
of:
_
___________________________________
(name of child who needs a guardian)
A Protected Minor.
CASE NO.: ____________________
DEPT: ____________________
LETTERS OF TEMPORARY GUARDIANSHIP
Expiration Date: _________________
On (month) ____________________ (day) ________, 20___, a Court Order was entered
appointing (name of first guardian) _________________________________________________
and (name of second guardian, or “n/a”) ____________________________________ as
Temporary Guardian(s) of the above named protected minor. The named Guardian(s), having
duly qualified, is/are authorized to act and has/have authority to perform the duties of such
Guardian(s) as provided by law for a period not to exceed 10 days, unless an Order Extending
Temporary Guardianship has been entered by the Court.
In testimony of which, I have this date signed these Letters and affixed the Seal of the
Court.
CLERK OF COURT
DATED ____________________________ BY: _____________________________________
DEPUTY CLERK
LETG
CLARK
Page 2 of 2 –
Temporary Letters of Guardianship (Child)
OATH
I, (name of guardian) _________________________________________________,
residing at (street/city/state/zip): ___________________________________________________
whose mailing address is (street/city/state/zip): _______________________________________
solemnly affirm that I will well and faithfully perform the duties of Temporary Guardian
according to law. I affirm that any matters stated in any petition, document or court proceeding
are true of my own knowledge or if any matters are stated on information or belief, 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.
EXECUTED this _____ day of _______________, 20___.
(Repeat Oath for Each Guardian; Attach Separate Sheets if Necessary)
(Signature)
(Printed Name)
This page explains what you need to do while you wait for your regular guardianship
“citation” hearing.
File your proof of service at least 1 week before your permanent guardianship
hearing. File the following documents to show all required people were notified:
Consents (if applicable). Any relative can sign a notarized consent if they
want you to be the guardian and will waive formal service of the documents.
The SHC has consent forms available. Any relative who will not sign a consent
must get the Petition and the Citation by certified mail, return receipt
requested.
Certificate of Mailing (required for anyone who won’t consent). This is
the proof that other relatives and agencies were served with the Petition and
the Citation.
o You must mail file-stamped copies of the Petition and the Citation to
the relatives and required agencies.
o Send the documents by certified mail, return receipt requested.
Use the “green cards” at the post office.
o File the Certificate of Mailing at least 1 week before your hearing.
Attach copies of the signed green cards when you receive them back
from each person.
An attorney will be there to represent the child you want to be the guardian
over. You may attend by phone or video. You can find forms to request a phone or
video appearance here: https://www.familylawselfhelpcenter.org/self-
help/guardianship/filing-for-guardianship-over-a-child/court-ordered-child-
guardianship/224-hearing
The child also needs to participate in the hearing. The judge cannot decide the case
without seeing the child first. Parents and relatives can come too. The judge will talk
to each person who is there to decide whether to approve the guardianship, deny the
guardianship, or set it for trial.
© 2018 Nevada Supreme Court
Page 1 of 2 – Certificate of Mailing (Child)
COURT CODE: CERT
Your Name:
Address:
City, State, Zip:
Telephone:
Email Address:
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Guardianship of the:
Person
Estate
Person and Estate
of:
_
___________________________________
(name of child who needs a guardian)
A Proposed Protected Minor.
CASE NO.: ____________________
DEPT: ____________________
CERTIFICATE OF MAILING FOR THE
PETITION FOR APPOINTMENT OF GUARDIANS
I HEREBY CERTIFY that I served the: ( check all that apply)
Petition for Appointment of Guardian
Citation to Appear and Show Cause
Other: ________________________________
on (month)_____________________ (day)_____, 20___, by depositing a copy of the same in
the U.S. Mail, enclosed in sealed envelopes, prepaid Certified Mail, Return Receipt Requested,
addressed to:
Relatives / Required Notices:
Name: ____________________________
Address: __________________________
____________________________
Name: ____________________________
Address: __________________________
____________________________
Page 2 of 2 – Certificate of Mailing (Child)
Name: ____________________________
Address: __________________________
____________________________
Name: ____________________________
Address: __________________________
____________________________
Name: ____________________________
Address: __________________________
____________________________
Name: ____________________________
Address: __________________________
____________________________
Name: ____________________________
Address: __________________________
____________________________
Name: ____________________________
Address: __________________________
____________________________
Name: ____________________________
Address: __________________________
____________________________
Name: ____________________________
Address: __________________________
____________________________
If the child receives or has received Medicaid, check the following box and mail to:
Director of the Department of Health and Human Services
4126 Technology Way, Suite 100
Carson City, Nevada 89706-2009
I declare under penalty of perjury under the law of the State of Nevada that the
foregoing is true and correct.
DATED (month) ________________________ (day) _______, 20___.
ATTACH THE SIGNATURE RECEIPTS (GREEN CARDS FROM THE
POST OFFICE) TO THIS FORM WHEN RECEIVED
(Signature)
(Printed Name)
/s/
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