Free Petition and Affidavit to Obtain Harassment Protection Order, DC 19:2 - Nebraska

STATE OF NEBRASKA FORM NO. DC 19-2 Rev. 6/08 Neb. Rev. Stat. § 28-311.09

PETITION AND AFFIDAVIT TO OBTAIN HARASSMENT PROTECTION ORDER

CASE NUMBER: DOCUMENT No.:

IN THE DISTRICT COURT OF

COUNTY, NEBRASKA

Petitioner vs.

PETITION AND AFFIDAVIT TO OBTAIN HARASSMENT PROTECTION ORDER

Respondent
1. I am the petitioner in this case. I am petitioning for a harassment protection order pursuant to Neb. Rev. Stat. § 28311.09. (If your age is less than nineteen (19) years old, state age: .) I am filing this petition on behalf of the following individuals who are family or household member(s): Name(s): Age(s): 2. Address: (Check Only One): My address is
(Street or Route/Box) (City) (State) (Zip)

Relationship(s)



Mailing address, if different: I am living in this county at an undisclosed address for my own protection. I have received address protection from the Secretary of State under the Address Confidentiality Program. (Service of any court process shall be made by mailing two copies of the process to the Office of Secretary of State, Address Confidentiality Program, Suite 2300, State Capitol Building, Lincoln, NE, 68509) am filing this petition against the
(City)

3. I

respondent

whose

age

is:
(State)

;

and

resides
(Zip)

at:

(Street or Route/Box)

Mailing address (if different) 4. The respondent is a person who has willfully harassed me and has engaged in a knowing and willful course of conduct directed at me which seriously terrifies, threatens, or intimidates me and serves no legitimate purpose. 5. I have been a party to the following past, pending, or current court proceedings (i.e., dissolution, paternity, custody, juvenile or protection orders). Indicate, when, type of case, name of court(s), and docket/case number(s).

6. I hereby ask the court to enter a protection order (mark all that apply): prohibiting the respondent from imposing any restraint upon me or upon my liberty; prohibiting the respondent from harassing, threatening, assaulting, molesting, or attacking me, or otherwise disturbing my peace; prohibiting the respondent from telephoning, contacting, or otherwise communicating with me.

7. I ( do, do not ) speak English. If you do not speak English, what language do you speak? . Does the respondent speak English? ( yes no ) If no, what language does respondent speak? 8. Nebraska law provides that you may choose a district court judge or county court judge to preside over protection order petitions. I choose to have a District Court Judge or a County Court Judge preside over this petition. 9. Describe the facts of the most recent series of acts of harassment toward me (and my family or household members.) A. Date/Time: Description:

B. Date/Time:

Description:

C. Date/Time:

Description:

I hereby swear, or affirm, under penalty of perjury, the foregoing affidavit is true.

Signature of Petitioner Subscribed and sworn on oath before me on ,

Clerk of the District Court/Notary Public

(Seal)