Form DC19:2 "Petition and Affidavit to Obtain Harassment Protection Order" - Nebraska

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What Is Form DC19:2?

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;
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  • Fill out the form in our online filing application.

Download a fillable version of Form DC19:2 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 DC19:2 "Petition and Affidavit to Obtain Harassment 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 HARASSMENT
DC 19:2 Rev. 11/17
PROTECTION ORDER
Neb. Rev. Stat. § 28-311.09
IN THE DISTRICT COURT OF
COUNTY, NEBRASKA
Case No.
Petitioner,
Additional Petitioner/Minor Child(ren),
PETITION AND AFFIDAVIT TO
OBTAIN HARASSMENT PROTECTION
ORDER
Additional Petitioner/Minor Child(ren),
.
vs
Respondent.
1. I,
, am the petitioner in this case. I am petitioning for a
harassment protection order pursuant to Neb. Rev. Stat. § 28-311.09.
I am filing this petition on behalf of:
Myself. I have been harassed.
Myself and additional petitioner(s) who have been harassed 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 have been harassed 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:
I am 19 or older or legally emancipated
OR
I am a minor and
years of age.
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)
(State)
(ZIP code)
(City)
Page 1 of 4
Petition and Affidavit to Obtain
Harassment Protection Order
DC 19:2 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 HARASSMENT
DC 19:2 Rev. 11/17
PROTECTION ORDER
Neb. Rev. Stat. § 28-311.09
IN THE DISTRICT COURT OF
COUNTY, NEBRASKA
Case No.
Petitioner,
Additional Petitioner/Minor Child(ren),
PETITION AND AFFIDAVIT TO
OBTAIN HARASSMENT PROTECTION
ORDER
Additional Petitioner/Minor Child(ren),
.
vs
Respondent.
1. I,
, am the petitioner in this case. I am petitioning for a
harassment protection order pursuant to Neb. Rev. Stat. § 28-311.09.
I am filing this petition on behalf of:
Myself. I have been harassed.
Myself and additional petitioner(s) who have been harassed 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 have been harassed 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:
I am 19 or older or legally emancipated
OR
I am a minor and
years of age.
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)
(State)
(ZIP code)
(City)
Page 1 of 4
Petition and Affidavit to Obtain
Harassment Protection Order
DC 19:2 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.
4.
I am filing this petition against the respondent whose age is:
and who resides at:
(Street or Route/Box)
(ZIP code)
(City)
(State)
Mailing address (if different)
(City)
(ZIP code)
(Street or Route/Box)
(State)
(Phone number)
The respondent does not speak English. The language that the respondent speaks is:
.
My relationship to the respondent is:
.
5.
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.
6. To my knowledge, 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).
7. I hereby ask the court to enter a protection order (mark all that apply):
prohibiting the respondent from imposing any restraint upon the person(s) seeking protection.
prohibiting the respondent from harassing, threatening, assaulting, molesting, attacking, or
otherwise disturbing the peace of the person(s) seeking protection.
prohibiting the respondent from telephoning, contacting, or otherwise communicating with the person(s)
seeking protection.
District Court Judge, or a
County Court Judge
8. Pursuant to Neb. Rev. Stat. § 25-2740, I request to have a
preside over this proceeding.(I understand this request may not be granted.).
9. The facts of the most recent series of acts of harassment toward the person(s) seeking protection are (Please
write a brief but detailed description.):
A. Date/Time:
Description:
Page 2 of 4
Petition and Affidavit to Obtain
Harassment Protection Order
DC 19:2 Rev. 11/17
B. Date/Time:
Description:
C. Date/Time:
Description:
10.
Additional Petitioner(s) (if needed):
Petitioner 2 (Minor Child):
Name:
Age:
Relationship to the Respondent:
___________________________________________________
_____________________________________
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:
___________________________________________________
Residence:
The address of this Petitioner is the same as my address above.
This Petitioner’s address is:
(ZIP code)
(Street or Route/Box)
(City)
(State)
Page 3 of 4
Petition and Affidavit to Obtain
Harassment Protection Order
DC 19:2 Rev. 11/17
Petitioner 4 (Minor Child):
Name:
Age:
Relationship to the Respondent:
___________________________________________________
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)
Petitioner 5 (Minor Child):
Name:
Age:
Relationship to the Respondent:
___________________________________________________
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)
Petitioner 6 (Minor Child):
Name:
Age:
Relationship to the Respondent:
___________________________________________________
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)
I hereby swear, or affirm, under penalty of perjury, the foregoing affidavit is true.
Signature of Petitioner
(Firm name and Bar Number IF being completed by an attorney)
(do NOT sign UNTIL THE CLERK OF THE DISTRICT COURT OR A NOTARY IS PRESENT AND WITNESSES YOU SIGNING)
Subscribed and sworn before me on
, 20
Clerk of the Court/Notary Public
(Seal)
My Commission Expires:
Page 4 of 4
Petition and Affidavit to Obtain
Harassment Protection Order
DC 19:2 Rev. 11/17
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