Form 4-972. Petition for emergency order of protection from domestic abuse.

[Family Violence Protection Act, Sections 40-13-1 to 40-13-8 NMSA 1978] STATE OF NEW MEXICO COUNTY OF _______________ __________________ JUDICIAL DISTRICT COURT STATE OF NEW MEXICO ON BEHALF OF: _______________________________, Petitioner v. No. __________ _______________________________, Respondent PETITION FOR EMERGENCY ORDER OF PROTECTION FROM DOMESTIC ABUSE1 1. INFORMATION ABOUT THE RESPONDENT The respondent is: [ ] the husband of [ ] wife of petitioner [ ] the ex-husband of [ ] ex-wife of petitioner [ ] a family member of petitioner (describe relationship) [ ] a person with whom petitioner has had a continuing personal relationship. (describe relationship) [ ] a person who has sexually assaulted me [ ] a person who has stalked me ________ Petitioner’s initials 2. CHILD(REN) List minor child(ren) who may be in immediate danger or in need of an order of temporary custody. Relationship of Child Name Date of Birth To Petitioner To Respondent _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ _______________ ________ Petitioner’s initials 3. DOMESTIC ABUSE A. The respondent committed the following act(s) of domestic abuse against petitioner or the petitioner's child(ren). (describe in detail what happened and when and where) Physical abuse: ________________________________________________________ ______________________________________________________________________ _____________________________________________________________________. Threats which caused fear that _________ or any household member would be injured: _______________________________________________________________ ______________________________________________________________________ _____________________________________________________________________. Other abuse: __________________________________________________________ ______________________________________________________________________ _____________________________________________________________________. B. Others present during the abuse:______________________________________ C. Did drugs or alcohol play a role in the domestic abuse? [ ] yes [ ] no D. Were weapons used during the abuse? [ ] yes [ ] no. If yes, what weapons? ______________________________________________ E. Has there been prior domestic abuse? [ ] yes [ ] no. ________ Petitioner’s initials 4. REQUESTS TO THE COURT THE COURT IS REQUESTED TO ENTER AN EMERGENCY ORDER OF PROTECTION prohibiting respondent from abusing petitioner or any member of petitioner's household as follows: (check applicable) [ ] providing for law enforcement officers to assist [ ] petitioner [ ] respondent in retrieving [ ] petitioner's [ ] respondent's clothing and personal belongings from the residence at __________________. [ ] granting petitioner temporary custody of the child(ren) listed in this petition. [ ] prohibiting respondent from contact with the child(ren) listed in this petition. [ ] other relief that is necessary to resolve this domestic abuse problem (list or describe what relief is necessary): ________ Petitioner’s initials 5. INFORMATION ABOUT THE PETITIONER (ME) (If you do not want the respondent to know your address and phone number, do not include it on this form. Tell the court clerk that you need a separate form (Form 4-961B NMRA) for your name and address and request that the clerk place your address under seal.) [ ] A. I DO NOT WANT RESPONDENT TO KNOW MY ADDRESS NOW OR AFTER THE HEARING FOR THE FINAL ORDER OF PROTECTION. I HAVE COMPLETED FORM 4-961B AND GIVEN IT TO THE COURT CLERK. OR [ ] B. My physical address is: ________________________ in the [ ] County [ ] Indian Country of __________________, State of New Mexico. My mailing address is: ________________________________________ (street address) ________________________________________ (city and zip) My telephone numbers are: Home ________________ Work ________________ Message ________________ ________ Petitioner's initials 6. LOCATION OF RESPONDENT A. Respondent may be found at: ______________________________ (address) ______________________________ (city) ______________________________ (state and zip code) ______________________________ (if in Indian Country, please name tribe or pueblo). Respondent’s: ______________________________ (date of birth) ______________________________ (home telephone number) ______________________________ (work address) ______________________________ (work telephone number). B. Is respondent in jail? [ ] yes [ ] no ________ Petitioner’s initials OATH OF PETITIONER I AFFIRM UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF NEW MEXICO THAT THE FACTS SET FORTH ABOVE ARE TRUE TO THE BEST OF MY INFORMATION AND BELIEF. ________________________________ Date ________________________________ Signature of petitioner OATH OF LAW ENFORCEMENT OFFICER I affirm under penalty of perjury under the laws of the State of New Mexico that the facts set forth above are true to the best of my information and belief. I understand that it is a criminal offense subject to the penalty of imprisonment if I make a false statement in this petition. ________________________________ Date ________________________________ Signature of law enforcement officer