Form DC19:8 "Petition and Affidavit to Obtain Domestic Abuse Protection Order" - Nebraska

What Is Form DC19:8?

This is a legal form that was released by the United States District Court for the District of Nebraska - a government authority operating within Nebraska. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on November 1, 2017;
  • The latest edition provided by the United States District Court for the District of Nebraska;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DC19:8 by clicking the link below or browse more documents and templates provided by the United States District Court for the District of Nebraska.

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Download Form DC19:8 "Petition and Affidavit to Obtain Domestic Abuse Protection Order" - Nebraska

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Nebraska State Court Form
REQUIRED
PETITION AND AFFIDAVIT TO
Do NOT complete form without reading instructions. Click HERE for Nebraska Self-Help instructions.
OBTAIN DOMESTIC ABUSE
DC 19:8 Rev. 11/17
PROTECTION ORDER
Neb. Rev. Stat. § 42-924
COUNTY, NEBRASKA
IN THE DISTRICT COURT OF
Petitioner,
Case No.
Additional Petitioner/Minor Child(ren),
Additional Petitioner/Minor Child(ren),
PETITION AND AFFIDAVIT TO
.
OBTAIN DOMESTIC ABUSE
vs
PROTECTION ORDER
Respondent.
1.
I, __________________________________________, am petitioning for a domestic abuse protection order
pursuant to Neb. Rev. Stat.§ 42-924. I am filing this petition on behalf of: (please check one)
Myself. I am a victim of domestic abuse.
Myself and additional petitioner(s) who are victims of domestic abuse and whose name(s) is/are shown
after mine in the caption of this petition. My relationship to the additional petitioner(s)/minor child(ren) is/are:
custodial parent,
guardian,
other: _________________________________.
Only on behalf of the additional petitioner(s) who are in fear of domestic abuse and whose name(s) is/are
shown after mine in the caption of this petition. My relationship to the additional petitioner(s)/minor child(ren)
is/are:
custodial parent,
guardian,
other: _________________________________.
AND:
OR
I am a minor and _________ years of age.
I am 19 or older or legally emancipated
I do not speak English. The language that I speak is: _____________________________.
2.
Check Only One:
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)
I am living at a safe house or shelter for my own protection. Pursuant to Neb. Rev. Stat. § 29-4303, I cannot
identify the name, address, location or phone number of the facility.
My address is
(Street or Route/Box)
(City)
(State)
(ZIP code)
Mailing address (if different)
(Street or Route/Box)
(City)
(State)
(ZIP code)
Page 1 of 6
Petition and Affidavit for Domestic Abuse
Protection Order
DC 19:8 Rev. 11/17
Nebraska State Court Form
REQUIRED
PETITION AND AFFIDAVIT TO
Do NOT complete form without reading instructions. Click HERE for Nebraska Self-Help instructions.
OBTAIN DOMESTIC ABUSE
DC 19:8 Rev. 11/17
PROTECTION ORDER
Neb. Rev. Stat. § 42-924
COUNTY, NEBRASKA
IN THE DISTRICT COURT OF
Petitioner,
Case No.
Additional Petitioner/Minor Child(ren),
Additional Petitioner/Minor Child(ren),
PETITION AND AFFIDAVIT TO
.
OBTAIN DOMESTIC ABUSE
vs
PROTECTION ORDER
Respondent.
1.
I, __________________________________________, am petitioning for a domestic abuse protection order
pursuant to Neb. Rev. Stat.§ 42-924. I am filing this petition on behalf of: (please check one)
Myself. I am a victim of domestic abuse.
Myself and additional petitioner(s) who are victims of domestic abuse and whose name(s) is/are shown
after mine in the caption of this petition. My relationship to the additional petitioner(s)/minor child(ren) is/are:
custodial parent,
guardian,
other: _________________________________.
Only on behalf of the additional petitioner(s) who are in fear of domestic abuse and whose name(s) is/are
shown after mine in the caption of this petition. My relationship to the additional petitioner(s)/minor child(ren)
is/are:
custodial parent,
guardian,
other: _________________________________.
AND:
OR
I am a minor and _________ years of age.
I am 19 or older or legally emancipated
I do not speak English. The language that I speak is: _____________________________.
2.
Check Only One:
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)
I am living at a safe house or shelter for my own protection. Pursuant to Neb. Rev. Stat. § 29-4303, I cannot
identify the name, address, location or phone number of the facility.
My address is
(Street or Route/Box)
(City)
(State)
(ZIP code)
Mailing address (if different)
(Street or Route/Box)
(City)
(State)
(ZIP code)
Page 1 of 6
Petition and Affidavit for Domestic Abuse
Protection Order
DC 19:8 Rev. 11/17
3.
I do not agree to receive notification by e-mail.
I agree to receive notification by e-mail.
e-mail address: _______________________________________________________
NOTE: By providing this e-mail address, I acknowledge that I am aware that this information will be
public record. I also understand that I will only receive e-mail communications regarding this case
from the court.
My relationship to the respondent is: (Check the ONE that best applies):
4.
spouse (husband or wife)
someone I am presently dating
former spouse
someone I have dated in the past
child
someone I am living with
Someone related to me in the following
someone I have lived with in the past
way: _______________________________________
the father/mother of one or more of
my children
Not applicable because requesting
only on behalf of other(s)
5.
I am filing this petition against the respondent whose age is:
, and who resides at:
(Street or Route/Box)
(City)
(State)
(Zip)
Mailing address (if different)
(Street or Route/Box)
(City)
(State)
(Zip)
(Phone number)
The respondent does not speak English. The language that the respondent speaks is:___________________
6.
The following are identifying characteristics for the respondent : Sex:______ Race: ______________
Skin Tone: _________________
Height: ___________________ Weight: _____________
Eye Color: ___________ Hair Color: ____________________
Driver’s License #: ______________________ State: ___________ Exp. Date: ____________________
Place of Birth: ____________________________ Scars/Marks/Tattoos: ________________________________
__________________________________________________________________________________________
Other distinguishing features:
__________________________________________________________________________________________
7.
The respondent and I
have
or
have not
been involved in past or current court cases
together. (i.e., divorce, paternity, custody, juvenile, criminal, or protection orders) If so: when, where,
type of case, name of court(s), and case number(s).
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Page 2 of 6
Petition and Affidavit for Domestic Abuse
Protection Order
DC 19:8 Rev. 11/17
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):
(specify address, location description, and connection of place to petitioner)
granting me temporary custody of the following minor children for ___________ days
:
(not to exce ed 90 days)
Name:
Age:
Residence:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
prohibiting the respondent from possessing or purchasing a firearm as defined in Neb. Rev. Stat. § 28-1201.
ordering any other relief deemed necessary to provide for the safety and welfare of me and any designated
family or household member, (describe relief requested and why):
10.
I reques t to have a
District Court Judge, or a
County Court Judge preside over this
proceeding.(I understand this request may not be granted.).
For purposes of the Protection from Domestic Abuse Act, abuse means the occurrence of one or more of the following acts:
11.
(a) attempting to cause or intentionally and knowingly causing bodily injury; (b) placing, by means of credible threat, another
person in fear of bodily injury (either verbally or in writing), or; (c) engaging in sexual contact or sexual penetration without
consent.
The facts of the most recent incidents of domestic abuse are as follows: (Please write a brief but detailed description of
each incident. Examples might including shoves, kicks or blows inflicted, weapons used, threats made, injuries sustained,
medical or hospital treatment necessary).
Page 3 of 6
Petition and Affidavit for Domestic Abuse
Protection Order
DC 19:8 Rev. 11/17
A. Date/Time:
Description:
B. Date/Time:
Description:
C. Date/Time:
Description:
Page 4 of 6
Petition and Affidavit for Domestic Abuse
Protection Order
DC 19:8 Rev. 11/17
Additional Petitioner(s)
12.
(if needed):
Petitioner 2 (Minor Child):
Name:
Age:
Relationship to the Respondent (from list on number 4):
___________________________________
_____
_____________________________________
___________________________________________________
Residence:
The address of this Petitioner is the same as my address above.
This Petitioner’s address is:
__________________________________________________________________________________
(Street or Route/Box)
(City)
(State)
(ZIP code)
Petitioner 3 (Minor Child):
Name:
Age:
Relationship to the Respondent (from list on number 4):
___________________________________
_____
_____________________________________
___________________________________________________
Residence:
The address of this Petitioner is the same as my address above.
This Petitioner’s address is:
_________________________________________________________________________________
(Street or Route/Box)
(City)
(State)
(ZIP code)
Petitioner 4 (Minor Child):
Name:
Age:
Relationship to the Respondent (from list on number 4):
___________________________________
_____
_____________________________________
___________________________________________________
Residence:
The address of this Petitioner is the same as my address above.
This Petitioner’s address is:
__________________________________________________________________________________
(Street or Route/Box)
(City)
(State)
(ZIP code)
Petitioner 5 (Minor Child):
Name:
Age:
Relationship to the Respondent (from list on number 4):
___________________________________
_____
_____________________________________
___________________________________________________
Residence:
The address of this Petitioner is the same as my address above.
This Petitioner’s address is:
__________________________________________________________________________________
(Street or Route/Box)
(City)
(State)
(ZIP code)
Petitioner 6 (Minor Child):
Name:
Age:
Relationship to the Respondent (from list on number 4):
___________________________________
_____
_____________________________________
___________________________________________________
Residence:
The address of this Petitioner is the same as my address above.
This Petitioner’s address is:
__________________________________________________________________________________
(Street or Route/Box)
(City)
(State)
(ZIP code)
Page 5 of 6
Petition and Affidavit for Domestic Abuse
Protection Order
DC 19:8 Rev. 11/17
Page of 6