Form 4-1001. Affidavit in support of a petition for an extreme risk firearm protection order.

[Extreme Risk Firearm Protection Order Act, NMSA 1978, Sections 40-17-1 to -13] STATE OF NEW MEXICO COUNTY OF __________________ __________________ JUDICIAL DISTRICT IN THE MATTER OF AN EXTREME RISK FIREARM PROTECTION ORDER FOR _______________________________ ___________________ (Respondent’s full date of birth) No. _________________________ AFFIDAVIT IN SUPPORT OF A PETITION FOR AN EXTREME RISK FIREARM PROTECTION ORDER (EXHIBIT A) 1. INFORMATION ABOUT THE PERSON WHO I BELIEVE POSES A SIGNIFICANT DANGER (RESPONDENT) A. The name of the person who I believe poses a significant danger of causing imminent personal injury to self or others by having custody or control or by purchasing, possessing, or receiving a firearm is: ________________________________________________________________ full legal name B. Respondent’s date of birth: _____________________________________ C. My relationship with this person is (please describe your relationship): ________________________________________________________________ D. Address of person (Respondent) who I believe poses a significant danger: ________________________________________________________________ street address ________________________________________ city __________ state __________ zip E. Firearms I believe the Respondent has custody of, controls, owns, or possesses: HANDGUN LONG GUN  Pistol  Revolver  Rifle  Shotgun Number _______ Number _______ Number _______ Number ________ Other : (includes any other firearms) ____________________________________________________________________ ____________________________________________________________________ Number _______ F. Location(s) of firearms: ________________________________________ ________________________________________________________________ G. Does the respondent also have ammunition?  Yes  No  Unknown H. Location(s) of the ammunition: __________________________________ ________________________________________________________________ 2. INFORMATION ABOUT ME (REPORTING PARTY) A. My full name: ________________________________________________ □ The respondent does not know my address and I do not want the respondent to see my address and contact information. If you do not want the respondent to know your address and contact information, do not write it on this form. You must fill out a Request to Omit Address form so the court knows how to contact you. B. My address: ________________________________________________________________ street or P.O. Box ________________________________________ city __________ state __________ zip C. I would like the court to contact me (including receiving notice of court hearings and orders) at:  the address I listed above OR  at the following address: ________________________________________________________________ street or P.O. Box ________________________________________ city __________ state __________ zip 3. FACTS I WANT THE COURT TO KNOW (You may attach additional pages, if needed) A. Any recent act or threat of violence by the respondent against self or others, regardless of whether the act or threat involved a firearm. Please describe: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ B. A pattern of acts or threats of violence by the respondent within the past twelve (12) months, including acts or threats of violence against self or others. Please describe: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ C. The respondent’s mental health history. Please describe: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ D. The respondent’s abuse of □ controlled substances and/or □ alcohol. Please describe: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ E. The respondent’s previous violations of any court order. Please describe: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ F. Previous extreme risk firearm protection orders issued against the respondent. Date of Order: _____________ Issued by: ______________________________ G. The respondent’s criminal history, including: arrests and convictions for violent felony offenses. Please describe: ________________________________________________________________ ________________________________________________________________ arrests and convictions for violent misdemeanor offenses. Please describe: ________________________________________________________________ ________________________________________________________________ arrests and convictions for crimes involving domestic violence or stalking. Please describe: ________________________________________________________________ ________________________________________________________________ H. The respondent’s history of the use, attempted use, or threatened use of physical violence against another person; of stalking another person; or of cruelty to animals. Please describe: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ I. Any recent acquisition or attempts at acquisition of a firearm by the respondent. Please describe: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ J. In addition, I would like the Court to also consider the following: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 4. LEGAL ACTION(S) BETWEEN THE RESPONDENT AND ME The following are legal actions between the Respondent and me. (You may attach additional pages, if needed) □ Lawsuit. Please describe: _________________________________________ □ Complaint. Please describe: _______________________________________ □ Petition. Please describe: _________________________________________ □ Restraining Order. Date Issued: ____________ Issued by: _______________ □ Injunction. Please describe: ________________________________________ □ Other Legal Action. Please describe: ________________________________ ________________________________________________________________ □ None. 5. AFFIDAVIT OF REPORTING PARTY I, _______________________________________________ (Reporting Party’s Name), hereby swear or affirm that I believe _________________________________ (Respondent’s Name), poses a significant danger of causing imminent personal injury to self or others by having custody or control or by purchasing, possessing, or receiving a firearm for the reasons sworn to in this Affidavit. _________________________________________ Signature _________________________________________ Printed Name Additional pages are attached to this Affidavit? □ YES □ NO STATE OF NEW MEXICO ) ) ss COUNTY OF ______________ ) Signed and sworn to before me on ________________________________________(date) by _______________________________________ (name of person making sworn statement). ______________________________ Signature of notarial officer (seal) My commission expires:_______________