Form DC19:71 "Information Worksheet for the Harassment Protection Order Packet" - Nebraska

What Is Form DC19:71?

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 May 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 DC19:71 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 DC19:71 "Information Worksheet for the Harassment Protection Order Packet" - Nebraska

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Reset Form
Do NOT complete form without reading instructions. Click HERE for Nebraska Self-Help instructions.
Information Worksheet For the Harassment Protection Order
When you complete the information on these pages on-line, your answers will transfer to the forms
that you will file with the court.
It is important to review each page to make sure they are complete before printing.
After printing, you will wait to sign until you are in front of the clerk of the court or a notary.
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 address***:
Street Address:
***If your address is confidential under Nebraska or
Federal law, check one of the options below.
Mailing address if different:
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)/minor child(ren):
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:
This Person's 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: ___________________________________________
Type in one of the above 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:
This Person's 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: ___________________________________________
Type in one of the above OR Pick from drop down list:
Page 1 of 4
DC 19:71 NEW 05/2018
HPO Packet
Reset Form
Do NOT complete form without reading instructions. Click HERE for Nebraska Self-Help instructions.
Information Worksheet For the Harassment Protection Order
When you complete the information on these pages on-line, your answers will transfer to the forms
that you will file with the court.
It is important to review each page to make sure they are complete before printing.
After printing, you will wait to sign until you are in front of the clerk of the court or a notary.
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 address***:
Street Address:
***If your address is confidential under Nebraska or
Federal law, check one of the options below.
Mailing address if different:
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)/minor child(ren):
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:
This Person's 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: ___________________________________________
Type in one of the above 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:
This Person's 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: ___________________________________________
Type in one of the above OR Pick from drop down list:
Page 1 of 4
DC 19:71 NEW 05/2018
HPO Packet
Full name of any additional petitioner(s) / Minor Child(ren),
4
Address is the same as mine.
Age:
Address if different:
This Person's 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: ___________________________________________
Type in one of the above 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:
This Person's 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: ___________________________________________
Type in one of the above 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:
This Person's 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: ___________________________________________
Type in one of the above 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?:
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.).
Page 2 of 4
DC 19:71 NEW 05/2018
HPO Packet
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.
To tell the court what type of protection you are asking for, Use this button to go to page 2 of the
Petition (number 7), check each type you are asking for.
Number 7
Please write a description of the most recent incident(s) of harassment.
For the purposes of Neb. Rev. Stat. § 28-311.09, Harass means to engage in a knowing
and willful course of conduct directed at a specific person which seriously terrifies,
threatens, or intimidates the person and which serves no legitimate purpose. Course of
conduct means a pattern of conduct composed of a series of acts over a period of time,
however short, evidencing a continuity of purpose, including a series of acts of following,
detaining, restraining the personal liberty of, or stalking the person or telephoning,
contacting, or otherwise communicating with the person. Go to page 3 of the Petition
(number 9) to write your description. This button will take you to that location:
Number 9
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. Go to that page to fill in this information.
IT IS KEPT CONFIDENTIAL.
IF YOU DO NOT HAVE ALL OF THE INFORMATION, COMPLETE AS MUCH AS YOU CAN.
DO NOT GIVE UP.
SS#/DOB/Gender
This button will take you to that page:
Page 3 of 4
DC 19:71 NEW 05/2018
HPO Packet
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 given the papers in? _________________________________
(This is also known as "being served")
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
Other directions for service can be entered on the Praecipe on page 1:
Praecipe, Page 1
Additional comments can be added on the Praecipe on page 2:
Praecipe, Page 2
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
DC 19:71 NEW 05/2018
HPO Packet
Nebraska State Court Form
PROTECTION ORDER
DC 19:1 Rev. 08/17
PRAECIPE
Neb. Rev. Stat. §§ 42-924 ,
28-311.09, and 28-311.11
COUNTY, NEBRASKA
IN THE DISTRICT COURT OF
,
Petitioner
Case No.
Additional Petitioner/Minor Child(ren) ,
PROTECTION ORDER
PRAECIPE
Additional Petitioner/Minor Child(ren),
.
vs
Respondent.
TO THE CLERK OF COURT:
Please have the Sheriff of
County serve a certified copy of the protection
order and/or order to show cause, petition, and request for hearing (if applicable) upon the respondent by
personal service at any one of the following addresses:
Home:
Work:
Other locations where respondent can be found:
Directions for service:
Date
Signature
Name
Street Address/P.O. Box
Check if completed by an attorney. Bar Number and Firm Name
City/State/ZIP Code
Phone
E-mail Address
(If you are concealing your address or phone, do not provide them. Make separate
arrangements with the clerk.)
Page 1 of 2
USE THIS BUTTON TO TAKE YOU BACK TO WHERE YOU LEFT OFF ON THE WORKSHEET
Protection Order Praecipe
DC 19:1 Rev. 08/17
Page of 11