Fillable PTPR Self-Represented DISTRICT COURT CLARK COUNTY, NEVADA (childrens (Family Law Self Help Center)

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PTPR Self-Represented DISTRICT COURT CLARK COUNTY, NEVADA (childrens (Family Law Self Help Center)

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© 2018 Family Law Self-Help Center Petition to Terminate Parental Rights
* You are responsible for knowing the law about your case. For more information on the law, this form, and free classes,
visit www.familylawselfhelpcenter.org or the Family Law Self Help Center at 601 N. Pecos Road. To find an attorney,
call the State Bar of Nevada at (702) 382-0504.
1
PTPR
Your Name:
Address:
Telephone:
Email Address:
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Parental Rights as to:
(children’s names)
____________________________________
____________________________________
____________________________________
Minor Child(ren).
CASE NO.: ____________________
DEPT: ____________________
PETITION TO TERMINATE PARENTAL RIGHTS
Petitioner (your name) ______________________________________ respectfully requests the
termination of the parental rights as detailed below, pursuant to NRS Chapter 128.
1. Petitioner. I am the (☒ check one) mother / father / legal guardian / other
(describe your relationship) ___________________________________ to the children.
2. Children and Parents.
Child’s Name Date of Birth Place of Birth (City/State)
The children live at the following address: ________________________________________
Address
________________________________________
City, State, Zip Code
Page 2 of 6 - Petition to Terminate Parental Rights
Children’s Mother:
__________________________________
Name
_________________________________
Address
__________________________________
City, State, Zip Code
*If the mother’s address is unknown, fill
out the information below.*
The mother’s nearest known adult
relative is (such as a parent, sibling, etc.):
__________________________________
Name Relationship
_________________________________
Address
__________________________________
City, State, Zip Code
Children’s Father:
__________________________________
Name
_________________________________
Address
__________________________________
City, State, Zip Code
*If the father’s address is unknown, fill
out the information below.*
The father’s nearest known adult relative
is (such as a parent, sibling, etc.):
__________________________________
Name Relationship
_________________________________
Address
__________________________________
City, State, Zip Code
3. Termination. The court should terminate the parental rights of the (☒ check one or both)
mother / father listed above.
4. Legal Guardian. A legal guardian is someone other than a parent who has been appointed
by a court or the parents (in writing) to care for the child. (☒ check one)
The children do not have a legal guardian.
The children do have a legal guardian. The guardian is:
_________________________________________
Name
_________________________________________
Address
_________________________________________
City, State, Zip Code
5. Caretaker. The children currently live with and are being cared for by: (☒ check one)
The mother
The father
The legal guardian
Other: ___________________________________
Name
___________________________________
Address
___________________________________
City, State, Zip Code
Page 3 of 6 - Petition to Terminate Parental Rights
6. UCCJEA Declaration. (☒ check one)
The children have lived in Nevada for the past six months, or since birth.
The children have NOT lived in Nevada for the past six months or since birth.
a. Living Arrangements Last 5 Years. The children have lived with the following
persons in the following places within the last five years:
Time Period
(mo/yr – mo/yr)
Name of Person the
Children Lived With
City and State Child’s Name (if
not all children)
______ - present
______ - _____
______ - _____
______ - _____
______ - _____
The names and current addresses of each non-parent the children lived with during the
last five years are:
b. Participation in Other Cases: (☒ check one)
I have / have not participated as a party or witness or in some other capacity in any
other case involving the children: (if you have, provide all specifics including the state, the
court, children involved, the case number and the date of the child custody order, if any):
c. Knowledge of Other Cases: (☒ check one)
I do / do not know of a different case that could affect the current case: (if you do,
provide all specifics including the state, the court, parties involved, the case number and
the nature of the proceeding):
d. Person(s) Who Claim Custody / Visitation: (☒ check one)
I do / do not know of anyone other than the parents who has physical custody of the
children or who claims custody/visitation rights to the children. (if so, list names and
addresses of anyone who claims custody/visitation rights)
Page 4 of 6 - Petition to Terminate Parental Rights
7. Parental Fault. Parental rights should be terminated because (☒ check all that apply):
Abandonment. The parent’s conduct shows that the parent intends to give up all
rights to the child. Specifically, the parent has not provided for the children’s support
and has not communicated with the children since (approximate date the parent last
had any contact with the children) ________________. Further proof of abandonment
includes: (explain)
Neglect. The parent has refused to provide proper food, clothing, shelter, education,
medical care, or other necessary care for the children’s physical, emotional, and
emotional needs. (explain):
Unfitness. The parent has failed to provide the children with proper care, guidance,
and support because of the parent’s fault, habit, or conduct. (explain):
Risk of Harm. The children would be at risk of serious physical, mental, or emotional
injury if they were returned to the parent. (explain):
Token Efforts. The parent has made only token efforts to care for the children.
(explain):
Sexual Assault. The child was conceived as a result of a sexual assault for which the
natural parent was convicted.
Page 5 of 6 - Petition to Terminate Parental Rights
8. Best Interest. It is in the children’s best interest to terminate parental rights because (explain
in detail)
9. American Indian Child. Upon information and belief: (☒ check one)
No, the children are not known to be American Indian children.
Yes, the children are known to be American Indian children.
10. Public Assistance. (☒ check one)
No, the children and I do not receive public assistance.
Yes, I or the children currently receive public assistance.
11. Name Change. If the parental rights are terminated: (☒ check one)
No, the children’s names should not be changed.
Yes, the children’s names should be changed to (write the complete first, middle, and
last name the child(ren) should have) ______________________________________
_____________________________________________________________________
because (explain why you want to change the name(s))
The child has not been convicted of a felony. Any child age 14 or older will file a
separate consent agreeing to the requested name change. The termination of parental
rights provides clear and compelling evidence that the substantial welfare of the child
necessitates the name change. This request is made pursuant to NRS 41.298.
Page 6 of 6 - Petition to Terminate Parental Rights
Petitioner requests:
1. That the Court grant the relief requested in this Petition; and
2. That the Court grant Petitioner sole legal and sole physical custody of the children; and
3. For such other relief as the Court finds to be just and proper.
DATED (month) _______________________ (day) _____, 20____.
Submitted By: (your signature) _________________________________
(print your name) __________________________________
VERIFICATION
Under penalty of perjury, I declare that I am the Petitioner in the above-entitled action;
that I have read the foregoing Petition and know the contents thereof; that the pleading is true of
my own knowledge, except for those matters therein contained stated upon information and
belief, and that as to those matters, I believe them to be true.
I declare under penalty of perjury under the law of the State of Nevada that the
foregoing is true and correct.
DATED (month) _______________________ (day) _____, 20____.
Submitted By: (your signature)
_________________________________
(print your name) __________________________________
/s/
/s/
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PTPR Self-Represented DISTRICT COURT CLARK COUNTY, NEVADA (childrens (Family Law Self Help Center)

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Completed 9 February 2021

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