Free Petition and Affidavit to Obtain Domestic Abuse Protection Order, DC 19:8 - Nebraska

STATE OF NEBRASKA FORM NO. DC 19-8 Rev. 6/08 Neb. Rev. Stat. § 42-924

PETITION AND AFFIDAVIT TO OBTAIN DOMESTIC ABUSE PROTECTION ORDER

CASE NUMBER: DOCUMENT No.:

IN THE DISTRICT COURT OF

COUNTY, NEBRASKA

Petitioner

vs.
Respondent 1.

PETITION AND AFFIDAVIT TO OBTAIN DOMESTIC ABUSE PROTECTION ORDER

I am the petitioner in this case. I am petitioning for a domestic abuse protection order pursuant to Neb. Rev. Stat. § 42-924. I am in fear of domestic abuse and provide the following information, under oath, in support of this application. If petitioner is less than nineteen (19) years old, state age: . I am filing this petition on behalf of the minor child(ren) whose name(s) is/are shown after mine in the caption of this petition.



2.



Check Only One: My address is
(Street or Route/Box) (City) (State) (Zip)

Mailing address (if different) Where removal of respondent from residence is necessary, physical location (legal description or directions to my residence) 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)

CONTINUED...

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3.

I am filing this petition against the respondent whose age is:
(Street or Route/Box) (City) (State)

, and resides at:
(Zip)

Mailing address (if different) 4. My relationship to the respondent is: (Check the ONE that best applies): spouse (husband/wife) a person I am presently involved with in a dating former spouse relationship child(ren) a person I was involved with in a dating relationship a person I am currently living with related to me by blood or marriage a person I have lived with in the past State Relationship the father/mother of one or more of my children The following are identifying characteristics for the respondent: Sex: _____ Race: _____________ Height: ______ Weight: _______ Eye Color: ________

5.

Hair Color: _________ Driver's License #: _______________________ State: ______ Exp Date: _________ Other distinguishing features: _________________________________________________________________ 6. 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 number(s).

7.

I ( do

do not) speak English. If you do not speak English, what language do you speak? no) If no, what language does respondent speak?

Does the respondent speak English? ( yes

8.

The respondent and I are parents of the following minor child(ren). Name Age Residence

I am the parent, but the respondent is not the parent, of the following minor child(ren):

9.

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 threatening, assaulting, molesting, or attacking me, or otherwise disturbing my peace; prohibiting the respondent from telephoning, contacting, or otherwise communicating with me; removing and excluding the respondent from my residence;

ordering the respondent to stay away from the following location(s):

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(specify address, location description, and connection of place to petitioner)



granting me temporary custody of the following minor children: for days (not to exceed 90days); order any other relief deemed necessary to provide for the safety and welfare of me and , a designated family or household member, including the following:

10.

Nebraska law provides that you may choose a district court 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.

11.

The facts of the most recent incident(s) of domestic abuse toward me (and my minor child(ren)) are as follows: (Please write a brief description of each incident including shoves, kicks or blows inflicted, weapons used, threats made, injuries sustained, medical or hospital treatment necessary, if any.)

A. Date/Time:

Description:

B. Date/Time:

Description:

CONTINUED...

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C. Date/Time:

Description:

I hereby swear, or affirm, under penalty of perjury, the forgoing affidavit is true. Signature of Petitioner Subscribed and sworn on oath before me on ,

Clerk of the District Court/Notary Public

(Seal)

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