Form DC19:28 "Harassment Protection Order Worksheet" - Nebraska

What Is Form DC19:28?

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. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2018;
  • 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 DC19:28 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 DC19:28 "Harassment Protection Order Worksheet" - Nebraska

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Information Worksheet For the Harassment Protection Order
This worksheet is to assist you in gathering information needed to complete
the petition and affidavit for a protection order, and is not filed with the
court. It is not required nor is it a substitute for the petition and affidavit.
For the “Petition and Affidavit to Obtain Harassment Protection Order”:
The county in which you will be filing the petition and affidavit:
Full name of the petitioner (your name):
Your street address***:
Street Address:
***If your address is confidential under Nebraska or
Mailing address if different:
Federal law, enter the county and state only.
I am receiving address protection from the Secretary of State.
I am living at a safe house or shelter.
I am 19 or older or legally emancipated.
What is your age?:
I am a minor.
If I am a minor my age is:
I do not speak English.
What language do you speak if you do not speak English?:
I am filing on behalf of myself,
myself AND additional petitioner(s),
on behalf of others ONLY
My relationship to the additional petitioner(s) if I am filing on behalf of myself and others is
custodial parent
guardian
other:
My relationship to the additional petitioner(s) if I am filing on behalf of the additional petitioner(s) ONLY is:
custodial parent
guardian
other:
My relationship to respondent - _______________________________________________
NOTE: This type of protection order does NOT require that there be a relationship with the respondent.
IF THERE IS NO CURRENT OR PAST RELATIONSHIP WITH THE RESPONDENT ENTER "N/A"
Full name of any additional petitioner(s) / Minor Child(ren),
2
Address is the same as mine.
Age:
Address if different:
Relationship to respondent - pick one: spouse (husband or wife), former spouse, child,
someone they are living with, someone they have lived with in the past, the father/mother of one or
more of their children, someone they are presently dating, someone they have dated in the past
someone related to them in the following way: ___________________________________________
Enter choice in the space to the right OR Pick from drop down list:
________________________________________________
Full name of any additional petitioner(s) / Minor Child(ren),
3
Address is the same as mine.
Age:
Address if different:
Relationship to respondent - pick one: spouse (husband or wife), former spouse, child,
someone they are living with, someone they have lived with in the past, the father/mother of one or
more of their children, someone they are presently dating, someone they have dated in the past
someone related to them in the following way: ___________________________________________
Enter choice in the space to the right OR Pick from drop down list:
________________________________________________
Page 1 of 4
Harassment Protection Order Worksheet
DC 19:28 Rev. 01/2018
Information Worksheet For the Harassment Protection Order
This worksheet is to assist you in gathering information needed to complete
the petition and affidavit for a protection order, and is not filed with the
court. It is not required nor is it a substitute for the petition and affidavit.
For the “Petition and Affidavit to Obtain Harassment Protection Order”:
The county in which you will be filing the petition and affidavit:
Full name of the petitioner (your name):
Your street address***:
Street Address:
***If your address is confidential under Nebraska or
Mailing address if different:
Federal law, enter the county and state only.
I am receiving address protection from the Secretary of State.
I am living at a safe house or shelter.
I am 19 or older or legally emancipated.
What is your age?:
I am a minor.
If I am a minor my age is:
I do not speak English.
What language do you speak if you do not speak English?:
I am filing on behalf of myself,
myself AND additional petitioner(s),
on behalf of others ONLY
My relationship to the additional petitioner(s) if I am filing on behalf of myself and others is
custodial parent
guardian
other:
My relationship to the additional petitioner(s) if I am filing on behalf of the additional petitioner(s) ONLY is:
custodial parent
guardian
other:
My relationship to respondent - _______________________________________________
NOTE: This type of protection order does NOT require that there be a relationship with the respondent.
IF THERE IS NO CURRENT OR PAST RELATIONSHIP WITH THE RESPONDENT ENTER "N/A"
Full name of any additional petitioner(s) / Minor Child(ren),
2
Address is the same as mine.
Age:
Address if different:
Relationship to respondent - pick one: spouse (husband or wife), former spouse, child,
someone they are living with, someone they have lived with in the past, the father/mother of one or
more of their children, someone they are presently dating, someone they have dated in the past
someone related to them in the following way: ___________________________________________
Enter choice in the space to the right OR Pick from drop down list:
________________________________________________
Full name of any additional petitioner(s) / Minor Child(ren),
3
Address is the same as mine.
Age:
Address if different:
Relationship to respondent - pick one: spouse (husband or wife), former spouse, child,
someone they are living with, someone they have lived with in the past, the father/mother of one or
more of their children, someone they are presently dating, someone they have dated in the past
someone related to them in the following way: ___________________________________________
Enter choice in the space to the right OR Pick from drop down list:
________________________________________________
Page 1 of 4
Harassment Protection Order Worksheet
DC 19:28 Rev. 01/2018
Full name of any additional petitioner(s) / Minor Child(ren),
4
Address is the same as mine.
Age:
Address if different:
Relationship to respondent - pick one: spouse (husband or wife), former spouse, child,
someone they are living with, someone they have lived with in the past, the father/mother of one or
more of their children, someone they are presently dating, someone they have dated in the past
someone related to them in the following way: ___________________________________________
Enter choice in the space to the right OR Pick from drop down list:
________________________________________________
Full name of any additional petitioner(s) / Minor Child(ren),
5
Address is the same as mine.
Age:
Address if different:
Relationship to respondent - pick one: spouse (husband or wife), former spouse, child,
someone they are living with, someone they have lived with in the past, the father/mother of one or
more of their children, someone they are presently dating, someone they have dated in the past
someone related to them in the following way: ___________________________________________
Enter choice in the space to the right OR Pick from drop down list:
________________________________________________
Full name of any additional petitioner(s) / Minor Child(ren),
6
Address is the same as mine.
Age:
Address if different:
Relationship to respondent - pick one: spouse (husband or wife), former spouse, child,
someone they are living with, someone they have lived with in the past, the father/mother of one or
more of their children, someone they are presently dating, someone they have dated in the past
someone related to them in the following way: ___________________________________________
Enter choice in the space to the right OR Pick from drop down list:
________________________________________________
I do not agree to receive notification by e-mail.
I agree to receive e-mail communications.
My e-mail address is: ____________________________________________________________
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.
Full name of the respondent (other party):
The respondent's address:
The respondent's telephone number:
The respondent's mailing address
if different:
What is the age of the respondent?:
The respondent does not speak English.
What language does the respondent speak if not English?:
Page 2 of 4
Harassment Protection Order
Worksheet
DC 19:28 Rev. 01/2018
The respondent goes by another name (alias). It is:______________________________________________
Identifying characteristics of the respondent:
Sex:
Race:
Height:
Skin tone:
Weight:
Eye Color:
Hair Color:
Driver's
Exp. Date:
License #:
State:
Place of
birth:
Scars/Marks/Tattoos:
Other distinguishing features:
The respondent and I
have
have not been involved in other court cases together. Name of court,
case number and determination of any other proceeding (divorce, paternity, custody, juvenile, criminal, or
protection orders…) that could affect this action.
You will be asked to write out a brief but detailed description of the most
recent incident(s) of harassment.
You will provide this description on page 2 of the Petition and Affidavit.
Pursuant to Neb. Rev. Stat. § 25-2740, I request to have a
District Court Judge, or a
County Court
Judge preside over this proceeding.(I understand this request may not be granted.).
Some of your confidential information is needed when you file for a protection order. You provide that on
the Social Security Numbers, Gender, and Birth Date(s) form.
THIS INFORMATION IS KEPT CONFIDENTIAL.
IF YOU DO NOT HAVE ALL OF THE INFORMATION, COMPLETE AS MUCH AS YOU CAN.
DO NOT GIVE UP.
Page 3 of 4
Harassment Protection Order Worksheet
DC 19:28 Rev. 01/2018
For the “Protection Order Praecipe” (additional information combined with above) :
Where the respondent works:
What hours/days the respondent works:
The respondent's WORK address:
What county do you want the respondent to be served in? _________________________________
Other locations that the respondent may be found:
Vehicle Information:
Make:
Model:
Year:
Color(s):
Lic Plate #:
State:
Type:
VIN (if available):
Other inforamtion:
Yes
No
Does the respondent carry a weapon or keep one nearby?:
Where and what kind?:
Yes
No
Have a history of mental illness?:
What kind?:
Yes
Use or abuse drugs or alcohol?:
No
What kind?:
No
Have a history of violence towards others?:
Yes
Make threats against law enforcement?:
Yes
No
Additional Comments can be added on page 2 of the Praecipe.
Other directions for service:
AFTER COMPLETING, LOOK AT ALL OF THE PAGES CAREFULLY.
IF YOU ARE COMPLETING THESE ON LINE, YOU MUST PRINT THEM TO SIGN.
DO NOT SIGN THE PETITION UNTIL YOU ARE IN FRONT
OF THE CLERK OF THE COURT OR A NOTARY.
Page 4 of 4
Harassment Protection Order Worksheet
DC 19:28 Rev. 01/2018
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