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Nebraska State Court Form
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DC 19:4 Rev. 01/2020
Neb. Rev. Stat. § 28-311.09 APR 11 2024
Document? (8100 __ JENNIFER L. NELSON
CLERK OF DISTRICT COURT
PHELPS COUNTY
IN THE DISTRICT COURT OF PHELPS COUNTY, NEBRASKA
CAROLYN SAMUELSON _ 7
Petitioner, Case No. . CI24-28 .
CASH SAMUELSON, CASEN SAMUELSON,
Additional Pétitioner/Minor Child(ren) ,
CORALYN SAMUELSON & CAIN SAMUELSON,
Additional Petitioner/Minor Child(ren) , EX PARTE HARASSMENT
vs. PROTECTION ORDER
DEREK SAMUELSON _ -—?
indent.
The protected party(ies) of this order is/are:
1. Carolyn Samuelson.
2. Cash Samuelson
3, Casen Samuelson
4, Coralyn Samuelson
5. Cain Samuelson
6 eee me
THE COURT, having received the Petition and Affidavit of the petitioner, finds
that a harassment protection order pursuant to Neb. Rev. Stat. § 28-311.09 should
be issued. FURTHER, it reasonably appears from the specific facts included in the
affidavit that irreparable harm, loss or damage will result before this matter can be
heard on notice, therefore, the court having jurisdiction of the parties finds that a
harassment protection order should be issued without prior notice and hearing.
IT IS THEREFORE ORDERED, pursuant to Neb. Rev. Stat. § 28-31 1.09, unless
otherwise dismissed or modified by order of the court, a harassment protection
order against the respondent is granted for a period of one year from the date of
this order and the petitioner is granted the following relief:
v 1. Respondent is enjoined from imposing any restraint upon the person
or liberty of the protected party(ies).
0a, Respondent is enjoined from harassing, threatening, assaulting,
molesting, attacking, or otherwise disturbing the peace of the protected
party(ies).
—
Vv 3. Respondent is enjoined from telephoning, contacting, or otherwise
communicating with the protected party(ies).
DC 19:4 Rev. 01/2020
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TOE
If the respondent wishes to appear and show cause why this order should not
remain in effect for a period of one year, he or she shall affix his or her current
address, telephone number, and signature on the Request for Hearing form
provided and return it to the clerk of the district court within ten (10) business
days after service upon him or her. This order shall remain in effect during the
time prior to the hearing. Costs are waived unless otherwise ordered by the court.
Dated: ye | Me __
Judge (eo _ —-
NOTICE TO RESPONDENT
PURSUANT to ig U.S.C.2265, this order is enforced in all fifty states, the
District of Columbia, tribal lands and U.S. territories. Moreover, pursuant to
18 U.S,C.922 if a final order is entered against you after a hearing of which you
had actual knowledge and an opportunity to participate, whether or not you
actually participated and if this court order restrains you from harassing,
stalking, or threatening an intimate partner or child of such intimate partner, or
engaging in other conduct that would place an intimate partner in reasonable fear
of bodily injury to the partner or child, you may be subject to a federal penalty
for possessing, transporting, or accepting a firearm or ammunition.
DC 19:4 Rev. 01/2020 Page
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PROTECTION ORDER INFORMATION - HARASSMENT
A harassment protection order is a court order issued to a victim who has been harassed,
pursuant to Neb. Rev. Stat. § 28-311.09 et seq.
In order to qualify for a harassment protection order:
a the petition shall state the events and dates of acts constituting the alleged harassment.
This must include the most recent and most severe incident(s).
the petitioner must show that the respondent has engaged in a knowing and willful course of
conduct directed at the petitioner which seriously terrifies, threatens, or intimidates the
petitioner and which serves no legitimate purpose.
° A course of conduct is defined as 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,
telephoning, contacting, or otherwise communicating with the petitioner.
A protection order may prohibit the respondent from:
. imposing any restraint upon the petitioner or family or household member, or liberty of the
petitioner,
harassing, threatening, assaulting, molesting, attacking, or otherwise disturbing the peace of
the petitioner,
. telephoning, contacting, or otherwise communicating with the petitioner.
Once the protection order petition is granted, it may not be withdrawn except upon order
of the court.
The protection order shall be effective for one year unless otherwise modified by the court.
A court, on its own motion or at the request of the petitioner, may treat a petition for a
harassment protection order as a request for a sexual assault protection order or domestic abuse
protection order, if it appears from the facts in the petition, affidavit and evidence presented at a
show-cause hearing that such other protection order is more appropriate.
NOTICE TO PETITIONER
Fees to cover costs associated with the filing, issuance, or service of a protection order shall not
be charged, except that a court may assess such fees and costs if the court finds that the
statements contained in the application were false and that the protection order was sought in
bad faith.
NOTICE TO RESPONDENT
If there has been an Ex Parte Protection Order served upon you and you wish to request a
hearing to show cause why the order should not remain in effect, you must request a hearing
on the provided “Request for Hearing” form by completing the form and returning it to the
DC 19:4 Rev. 01/2020 Page 3 of 4 Ex Parte Harassment Protection Order
clerk of the district court at the address listed at the bottom of the form. You must return the
form within ten (10) business days after you have been served. The court will schedule a hearing
within thirty (30) days after reviewing our request and shall notify you and the petitioner of the
hearing date.
If there is a hearing scheduled and you wish to defend against the claims set forth in the
application for a protection order, you must appear at the hearing. You are warned that if you fail
to appear, the case will proceed without you and a final order may be entered against you for
the relief requested in the petition.
You are required to obey the terms of the protection order as soon as it is served upon you. If
you disobey the terms of the protection order, you will be subject to the following Nebraska
Revised Statutes.
Violation of a Protection Order: Any person convicted of violating the terms of a harassment
protection order after being served shal] be subject to either Neb. Rev. Stat. § 28-311.04 or
§ 28-311.09(4).
If a protection order has been issued against you, the following United States Federal Statutes
apply to the issuance of a valid protection order.
Full Faith and Credit Provision: Pursuant to 18 U.S.C. § 2265, this order is enforceable in all
fifty (50) states, the District of Columbia, tribal lands and U.S. territories. The penalties for
violation of this order are determined by the existing penalty of the location in which the violation
oceurred. Nebraska’s Harassment Full Faith and Credit provisions are found in Neb. Rev. Stat.
§ 28-311.10.
Interstate Domestic Violence/Violation of a Protection Order:
. Ifyou travel across state or tribal borders with the intent to injure the petitioner and then
intentionally commit a crime of violence causing bodily injury to the petitioner, you may be
convicted of committing a federal offense under 18 U.S.C. § 2261(a}(1). You may also be
convicted of committing a federal offenseif you cause the petitioner to cross state or tribal
borders for this purpose. 18 U.S.C. § 2262(a)(2).
If you travel across state or tribal borders with the intent to violate the final protection order
and subsequently violate such order, you may be convicted of committing a federal offense
under 18 U.S.C. § 2261(a)(1).
You may also be convicted of committing a federal offense if you cause the plaintiff to cross
state or tribal borders for this purpose. [8 U.S.C. § 2262(a)(2).
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