Form 4-1001.1. Law enforcement statement 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. _________________________ LAW ENFORCEMENT STATEMENT 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. Address of the person (Respondent) who I believe poses a significant danger: ___________________________________________________________________ street address __________________________________________ city __________ state __________ zip D. Firearms I believe the Respondent has custody of, controls, owns, or possesses: Type of Firearm Number Location Ammunition □ Long gun (includes rifles and shotguns) □ Yes □ No □ Unknown □ Handgun (includes revolvers and pistols) □ Yes □ No □ Unknown □ Other (includes any other firearms): □ Yes □ No □ Unknown TOTAL NUMBER OF RESPONDENT’S FIREARMS: _____________________ 2. INFORMATION ABOUT LAW ENFORCEMENT OFFICER COMPLETING STATEMENT A. Employed by the following type of agency:  Police Department  District Attorney’s Office  Sheriff’s Office  Attorney General’s Office  State Police B. Full name: _______________________________________________________ C. Badge/CAID Number _______________________________________________ D. Law Enforcement Agency you work for: ________________________________ E. Law Enforcement Agency address: ________________________________________________________________ street address __________________________________________ city __________ state __________ zip F. Law Enforcement Agency’s telephone number: __________________________ 3. Description of circumstances under which I collected credible information that gave rise to the petition: (You may attach additional pages, if needed) ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 4. Statement of 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 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: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 5. AFFIDAVIT OF LAW ENFORCEMENT OFFICER I, ______________________ (Law Enforcement Officer’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 Statement. ____________________________________ Signature ____________________________________ Printed Name Additional pages are attached to this Affidavit? □ YES □NO