FILING CODE: COMD

Your Name: _________________________

Address: ____________________________
2855 N Walnut Rd
City, State, Zip: Las
______________________
Vegas NV 89115
Phone: _____________________________
(951) 438-6777
Email: ______________________________
Deboortiz84@yahoo.com
Self-Represented Plaintiff

DISTRICT COURT
CLARK COUNTY, NEVADA

________________________________ CASE NO.: ____________________

Plaintiff,
DEPT: ____________________
vs.

Joanna Serna Ortiz

________________________________
Defendant.

COMPLAINT FOR DIVORCE AND UCCJEA DECLARATION (With Children)

Plaintiff (your name) _________________________________________ respectfully states:

1. Residency. Which spouse has been a resident of the State of Nevada for at least six
weeks prior to filing this Complaint?  Me /  Defendant.

July 5 2016
2. Marriage. The parties were married on (date) ______________________________ in
Victorville
(city) __________________, California
(state) _________________. The parties are incompatible.
The parties have been living separately and apart since (date) ____________________.
October 2022

3. Pregnancy. (☒ check one)

 Neither spouse is pregnant.
Joanna Serna Ortiz
 The following spouse is pregnant: (name of pregnant spouse) __________________.
The other spouse  is /  is not the parent of the unborn child. The child is due to be
born on (date): _________________.
Unknown
 It is unknown whether either spouse is currently pregnant.

© 2023 Family Law Self-Help Center Complaint for Divorce (With Kids)

* 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
4. Children. There are (number) _______
2 minor children in common:

Date of State of How long child

Child’s Name Birth Residence lived in the state Disability
Alfonso Serna Ortiz 01/26/18 Nv 1.5years N
Emily Serna Ortiz 07/9/19 Nv 1.5 years N

5. UCCJEA Declaration. Have the children lived in Nevada the last six months, or since
birth? (☒ check all that apply)

 Yes, the child(ren) have lived in Nevada for the past six months, or since birth.
 No, the child(ren) have NOT lived in Nevada for the past six months.

a. Children’s Residence Last 5 Years. The children have lived with the following
persons in the following places within the last five years:

Who they Dates they live(d) Which child

Where they live(d)
live(d) with there (or all)
Examples  123 Main, Las Vegas Sue & Mark Jones May 2021- Feb 2022 All

Current:
July 2023 - present
2855 N Walnut, Las Vegas Obed All
May2023 - July2023
Past Residence: 3741 E Pecan, Las Vegas Obed All
Past Residence: 12970 Grinnell, Victorville Obed
October 2022 - May2023
All
Past Residence: 8593 Rolling Hills Dr, Corona Obed October 2019 - October 2022
All

If the children lived with a non-parent in the last 5 years, list the non-parent’s name and
current address:

Page 2 of 9 - Complaint for Divorce (With Kids)

 b. Participation in Other Cases. Have you ever participated in any case concerning
these children as a party, witness, or in some other capacity? (☒ check one)

 No.
 Yes, I have participated in the following cases concerning these children (provide
all specifics including the state, the court name, children involved, the case
number and the date of the child custody order, if any):

c. Knowledge of Other Cases. Do you know of any other case that could affect this
case, such as other custody cases, domestic violence cases, protection order cases, or
adoptions/terminations? (☒ check one)

 No.
 Yes, the following cases that could affect this case (give all specifics including the
state, the court name, the parties involved, the case number and the type of case):

d. Person(s) Who Claim Custody / Visitation. Is there anyone other than yourself or
other parties to this case who has custody of the children or who can claim a right to
custody or visitation with the children? (☒ check one)

 No.
 Yes, the following people have custody or can claim custody/visitation of the
children: (list names and addresses of anyone who claims custody/visitation
rights):

6. Legal Custody. Legal custody refers to the ability to make major decisions about the
child, such as medical care, education, and religious upbringing. (☒ check one)

 The parties should share joint legal custody of the child(ren).

 Plaintiff should have sole legal custody of the child(ren).
 Defendant should have sole legal custody of the child(ren).
 Nevada is not the “home state” of the child(ren) and cannot enter custody orders.

Page 3 of 9 - Complaint for Divorce (With Kids)

7. Physical Custody. Physical custody refers to the amount of time the child spends with
each parent. (☒ check one)

 Joint Custody. The parties should share joint physical custody of the child(ren)
(each parent must have the child(ren) roughly 40% of the time, or 146 days per
year). A proposed parenting timeshare and holiday schedule is attached as Exhibit 1.
 Primary Custody. The (☒ check one)  Plaintiff /  Defendant should have
primary physical custody of the child(ren). A proposed parenting timeshare and
holiday schedule is attached as Exhibit 1.
 Sole Custody. The (☒ check one)  Plaintiff /  Defendant should have sole
physical custody of the child(ren).
 Nevada is not the “home state” of the child(ren) and cannot enter custody orders.

8. Other Considerations. The Court should consider the following issues in determining
custody: (☒ check all that apply)

 Domestic Violence  State of Residency

 CPS Involvement  Other: _____________________
 Military Deployment

9. Public Assistance. Has either party ever received public assistance? (☒ check one)
 No, the parties in this case have never received public assistance.
 Yes, one or more parties now receives or has received public assistance.

10. Parties’ Incomes. The court needs to know both parties’ gross monthly incomes to make
sure child support is set correctly.

Gross monthly income includes money received from work, social security, unemployment,
pension/retirement, interest/investments, veteran’s benefits, military allowances, etc.

It does not include SSI, SNAP, TANF, cash benefits from the county, or child support
received.
5,200
My gross monthly income is (insert amount): $_________ / OR  unknown.
3500
The other parent’s gross monthly income is (insert amount): $_________ / OR  unknown.

Page 4 of 9 - Complaint for Divorce (With Kids)

11. Child Support. Use the attached worksheet to figure out how much child support the court
should order. Complete the worksheet before filling out this section. (☒ check one)

 Child support should be paid by (name of parent who should pay child support)
_________________________________ in the amount of $_________ per month.
This is based on: (☒ check one)
 The Child Support Worksheet calculation attached.
 The amount already established by the District Attorney, Family Support
Division, case (insert case number) R__________________.

 No child support is requested. (Explain why not):

I don't need it.
 I’m not sure how much child support should be paid, and ask the court to set support.

Any final child support ordered will be due the 1st of the month beginning the
month after the case is finalized and the decree is filed. Payments may be made
directly between the parties, or either party may open a child support collection
case with the local Child Support Enforcement Office.

12. Back Child Support. Should back child support (“arrears”) be ordered? (☒ check one)
 No, no back child support or arrears are requested.
 Child support arrears are being handled by the District Attorney, Family Support
Division, case (insert case number) R__________________ and should continue as
ordered in that case.
 Yes, back child support should be paid by (name of parent who should pay back child
support) ____________________________________ from (date back child support
should begin) ___________________ to present.

13. Child Care. Are there child care expenses? (☒ check one)
 No, there are no child care costs for either parent.
 Yes, the monthly child care costs for the child(ren) are: $_________. This amount
should be paid by  me only  the other parent only  both parents equally.

Page 5 of 9 - Complaint for Divorce (With Kids)

14. Medical Coverage. Medical support (medical, vision, and/or dental) must be provided
for the child(ren). How will the children get medical support/insurance?

 Medicaid.
 Private / Employer Insurance. The monthly premium should be paid by  me only
 the other parent only  both parents equally.
 Other:

15. Unreimbursed Medical Expenses. How will medical expenses get paid if insurance
does not cover a medical cost? (☒ check one)

 Both parents should equally pay any expenses not covered by insurance.
 One parent should pay any expenses not covered by insurance, that parent is (name of
Obed Serna Ortiz
parent who should pay) ______________________________________.

16. “30/30 Rule.” The “30/30 Rule” provides that if a parent pays a medical or dental
expense for a child that is not paid by insurance, that parent must send proof of payment
of the expense to the other parent within 30 days of paying the expense. The other parent
then has 30 days to reimburse the paying parent ½ the cost. Do you want the 30/30 rule
ordered in your case? (☒ check one)

 Yes, the Court should order the 30/30 Rule for payment of all unreimbursed medical /
dental expenses.
 No, the Court should not order the 30/30 Rule for payment of unreimbursed medical /
dental expenses.

17. Tax Deduction. IRS rules state that the custodial parent usually has the right to claim
the child on their taxes. The custodial parent can waive this right by filling out IRS Form
8332. Talk to a tax professional if you are not sure what to do. (☒ check all that apply)

 Plaintiff should claim the following children as dependents for tax purposes every
year: (insert child(ren)’s names): _____________________________________
Alfonso & Emily Serna Ortiz
 Defendant should claim the following children as dependents for tax purposes every
year: (insert child(ren)’s names): _____________________________________
 The tax deduction should alternate, with Plaintiff claiming the child(ren) in (☒ check
one)  even /  odd years, and Defendant claiming the child(ren) the other years.
 The tax deduction should be allocated per federal law.

Page 6 of 9 - Complaint for Divorce (With Kids)

18. Community Property. (☒ check one)
 There is no community property to divide.
 Any community property has already been divided.
 I do not know the full extent of the community property.
 The community property should be divided as follows:
Property to Plaintiff:
1. ______________________________________________________
2. ______________________________________________________
3. ______________________________________________________
4. ______________________________________________________
Property to Defendant:
1. ______________________________________________________
2. ______________________________________________________
3. ______________________________________________________
4. ______________________________________________________

19. Community Debt. (☒ check one)

 There is no community debt to divide.
 Any community debt has already been divided.
 I do not know the full extent of the community debt.
 The community debt should be divided as follows:
Debts to Plaintiff:
1. ______________________________________________________
2. ______________________________________________________
3. ______________________________________________________
4. ______________________________________________________
Debts to Defendant:
1. ______________________________________________________
2. ______________________________________________________
3. ______________________________________________________
4. ______________________________________________________

Page 7 of 9 - Complaint for Divorce (With Kids)

 20. Alimony. (☒ check one)
 No spousal support is requested.
 Plaintiff should pay $________ per month in spousal support for the next (number)
_______ years.
 Defendant should pay $________ per month in spousal support for the next (number)
_______ years.

21. Name Change. (☒ check one)

 Plaintiff does not request a name change.
 Plaintiff would like to be restored to his/her former name of (insert former name you
would like to go back to) ____________________________________________.

22. If Plaintiff is able to hire counsel, attorney’s fees and costs are requested.

Plaintiff requests:
1. That the marriage existing between Plaintiff and Defendant be dissolved and that
Plaintiff be granted an absolute Decree of Divorce and that each of the parties be
restored to the status of a single, unmarried person;
2. That the Court grant the relief requested in this Complaint; and
3. For such other relief as the Court finds to be just and proper.

September
DATED (month) _______________________ 1
(day) _____, 24
20____.

Submitted By: (your signature)  _______________________________

(print your name) _______________________________

Page 8 of 9 - Complaint for Divorce (With Kids)

 VERIFICATION

Under penalty of perjury, I declare that I am the Plaintiff in the above-entitled action; that
I have read the foregoing Complaint 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) _______________________

September (day) _____,
1 20____.
24

Submitted By: (your signature)  _______________________________

(print your name) _______________________________

Page 9 of 9 - Complaint for Divorce (With Kids)

 EXHIBIT 1: Parenting Timeshare and Holiday Schedule

✘ No Visitation Requested Because: (explain) ______________________________

Regular Schedule:
Be very specific. Include _____________________________________________________
the times and days of the
week for each parent’s _____________________________________________________
timeshare. _____________________________________________________
(ex.: Mom: Saturday 7pm –
Wednesday 3pm, _____________________________________________________
Dad: Wednesday 3pm – _____________________________________________________
Saturday 7pm)
_____________________________________________________
_____________________________________________________

Summer Schedule:  Same as the regular schedule.

 Other: ____________________________________________

Mother’s Day and Mother’s  Mother every year from 9am – 7pm.
Birthday:  Other: ____________________________________________

Father’s Day and Father’s  Father every year from 9am – 7pm.
Birthday:  Other: ____________________________________________

Child’s Birthday:  Even years with (parent) ___________________________.

Odd years with (parent) ____________________________.
*Time shall be from 9am – 7pm.*
 Other: ___________________________________________

3 Day Weekends:  Even Years: MLK Jr. Day, Memorial Day, Labor Day with
(parent) _________________________________,
President’s Day, Independence Day, Nevada Admissions
Day with the other parent.
Odd Years: MLK Jr. Day, Memorial Day, Labor Day with
(parent) _________________________________,
President’s Day, Independence Day, Nevada Admissions
Day with the other parent.
*Time begins when school lets out the day before the holiday
weekend (or 3pm if no school), and ends the day following
the holiday weekend when school resumes (or 9am).*
**If Independence Day falls on a Tuesday, Wednesday, or
Thursday, the time shall be from July 3 at 9am until July 5
at 9am.**
 Other: ____________________________________________
Easter / Spring Break:  Even years with (parent) _____________________________.
Odd years with the other parent.
*Time shall begin the day school lets out until noon the day
before school resumes.*
 Other: ____________________________________________

Thanksgiving:  Odd years with (parent) _____________________________.

Even years with the other parent.
*Time shall begin the day school lets out until noon the day
before school resumes.*
 Other: ____________________________________________

Winter Break / Christmas:  Segment 1 (Christmas) consists of the day school lets out until
December 26 at noon.
Segment 2 (New Year’s) consists of December 26 at noon
until noon the day before school resumes.
Even years: segment 1 with (parent) ____________________,
segment 2 with the other parent.
Odd years: segment 1 with (parent) ____________________,
segment 2 with the other parent.
 Other: ____________________________________________
_________________________________________________

Other Holidays:
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________

Vacation:  The parents will not establish a formal vacation plan, and will
instead mutually agree on vacation days and times with the
child(ren).
 Each parent may have up to (number) ______ vacation days
per year with the child(ren). The parent shall notify the other
parent of the vacation and provide a general vacation itinerary
at least (number) _____ days before the planned vacation.
Vacation time is not allowed during a holiday allotted to
the other parent.
 Child Support Worksheet
The Other Parent’s Information
How much money does the other parent make every month? (Estimate if you do not know. A GMI
worksheet is attached if you need help.)
Figure out the other parent’s gross monthly income. This includes money received from employment, social
security, unemployment, pension/retirement, interest/investments, etc.
It does not include SSI, SNAP, TANF, cash benefits from the county, or child support received.

3500
I believe the other parent makes $_______________ per month (this is “Gross Monthly Income”)
*If this number is more than $6000, STOP. This worksheet will not apply.
Visit nvchildsupportguidelinescalculator.azurewebsites.net/getobligation.aspx to find the appropriate amount.

Determine what the other parent’s child support obligation would be:
.16 (for 1 child)
Gross Monthly Income X .22 (for 2 children) = Regular Child Support:
(from above)
.26 (for 3 children)
$ ____________
770
$ ___________
3500 .28 (for 4 children)
Add .02 for each additional child

Does this parent earn less than $1883 per month?

 No. (skip to )
 Yes. The court may use the low-income child support schedule Low Income Child Support:
instead. (check the attached chart to find the right number to enter. $ ____________
Use this number in steps & )

Your Information (complete this section even if you expect the other parent to pay child support)
How much money do you make every month? (A GMI worksheet is attached if you need help.)
Include money you get from employment, social security, unemployment, pension/retirement, interest /
investments, etc. Do not include SSI, SNAP, TANF, cash benefits from the county, or child support received.

5,200
I make $_______________ per month (this is “Gross Monthly Income”)
*If this number is more than $6000, STOP. This worksheet will not apply.
Visit nvchildsupportguidelinescalculator.azurewebsites.net/getobligation.aspx to find the appropriate amount.

Determine what your child support obligation would be:

.16 (for 1 child) Regular Child Support:
Gross Monthly Income X .22 (for 2 children) =
(from above)
.26 (for 3 children) 1144
$ ____________
5,200
$ ___________ .28 (for 4 children)
Add .02 for each additional child
Do you earn less than $1883 per month?
 No. (skip to )
 Yes. The court may use the low-income child support schedule Low Income Child Support:
instead. (check the attached chart to find the right number to enter. $ ____________
Use this number in steps & )

© 2024 Family Law Self-Help Center Child Support Worksheet

 Joint Custody. Only fill out this section if you are asking for Joint Physical Custody.
Skip to if you are asking for primary custody, sole custody, or visitation only.

Subtract the lower earning parent’s amount of child support from the higher earning parent’s amount.

Higher Lower Child Support Obligation Name of higher income parent:

$ _______ - $ _______ = $____________ paid by ____________________

Adjustments.
If you want primary or sole physical custody, the court uses the number in as the standard
amount of child support the other parent would pay.

If you want the other parent to have primary or sole physical custody, the court uses the number
in as the standard amount of child support you would pay.

If you want both parents to have joint physical custody, the court uses the number in as the
standard amount of child support.

You can ask for more or less child support than the amount in or if you think any of the following
factors apply. ( check all that apply, or skip to if none if these reasons apply)
 Special educational needs  Cost of transportation to and from visitation

✘ A parent’s legal responsibility to support others  The relative income of both households
 The value of services contributed by either  Any other necessary expenses for the benefit
parent of the child
 Public assistance paid to support the child  The obligor’s ability to pay

Explain:

Final Child Support Amount Requested:

$ ___________ paid by (name) _____________________________________

© 2024 Family Law Self-Help Center Child Support Worksheet

 TO DETERMINE A PARENT’S GROSS MONTHLY INCOME (“GMI”) FROM EMPLOYMENT
Annual Income $ Biweekly Income $
÷ by 12 months = GMI $ X 26 pay periods per year
÷ by 12 months = GMI $

Weekly Income $ Hourly Wage $

X 52 pay periods per year # of hours worked per week
Subtotal = hourly wage X #
÷ by 12 months = GMI $ of hours per week $
X 52 pay periods per year
÷ by 12 months = GMI $

LOW INCOME CHILD SUPPORT SCHEDULE

FOR PARENTS WHO EARN LESS THAN $1883 PER MONTH

© 2024 Family Law Self-Help Center Child Support Worksheet