4-961

[Standard simplified petition form,

Family Violence Protection Act,

Sections 40-13-1 to 40-13-8 NMSA 1978.]

[District Court Civil]

STATE OF NEW MEXICO

COUNTY OF _______________

___________________ JUDICIAL DISTRICT

No. ____________

_____________________________, Petitioner

_____________________________, Respondent

PETITION FOR ORDER OF PROTECTION

FROM DOMESTIC ABUSE¹

1. COURT ASSISTANCE REQUEST

[ ] We will need an interpreter in _____________ to translate at hearings for [ ] me [ ] the respondent.

[ ] We will need ___________________________________________ (describe other request for special help).

2. INFORMATION ABOUT THE RESPONDENT (the person I am filing against)

A. The respondent is:

[ ] my husband or [ ] my wife

[ ] my ex-husband or [ ] my ex-wife

[ ] the parent of my [child] [children]

[ ] a family member _____________________ (describe the family relationship)

[ ] a person with whom I have had a continuing personal relationship _______________________________________________ (describe the relationship)

B. The respondent has the following weapons: ___________________

3. [CHILD] [CHILDREN]²

A.List minor [child] [children] of either party.

Name Date of Relationship of [Child] [Children]

Birth To You To Respondent

__________________ __________ __________ __________

B. List address and with whom the [child] [children] are currently living. (List each child separately if [child] [children] do not reside with same person.)

_______________________________________________________________

C.List each address where [child] [children] have lived during the last [3] (5) five years. (List each child separately if [child] [children] did not reside with same person.)

_______________________________________________________________

D.Does anyone else have physical custody of the [child] [children] or claim to have custody or visitation rights? [ ] yes [ ] no

If yes, complete the following for the [child] [children]:

Child's namePerson claiming rights

__________________________________________________

4. OTHER CASES

[ ] The following divorce, separation, order of protection, child support, paternity, abuse or neglect cases have been previously filed by me, the respondent or the state:

Type of Case Year Filed Case Number Where Filed

(if known) (if known) (city and state)

__________________________________________________

5. DOMESTIC ABUSE

A.The respondent committed the following act(s) of domestic abuse against me or a member of my household: (describe in detail what happened to you or to a member of your household and when and where.)

Physical abuse: ________________________________________________

______________________________________________________________.

Threats which caused fear that you 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

6. REQUESTS TO THE COURT

I REQUEST THAT THE COURT ORDER (check all that you want):

[ ] A. that the respondent not contact me, not abuse me and that the respondent stay away from my residence [and] [place of employment] [and] [school].

[ ] B. (1) that the respondent shall immediately leave [ ] my [ ] our residence.

[ ] (2) that the respondent provide me with temporary suitable alternative housing.

[ ] C. that the respondent shall not sell, remove, pawn, hide, destroy or damage any property owned by me or the two of us jointly.

[ ] D. that law enforcement officers assist me in retrieving my clothing and personal belongings from the residence at ____________________________________________________.

[ ] E. that I be given temporary custody of the [child] [children] listed in this petition.

[ ] F. that until the court hearing:

[ ] respondent shall have the following contact with the [child] [children]: _________________________

____________________________________________.

[ ]respondent shall have no contact with the [child] [children].

[ ] G. that the respondent shall pay:

[ ] support for the [child] [children]

[ ] support for me.

[ ] H. that the respondent shall pay me for the damage and medical bills resulting from the abuse.

[ ] I. other relief that is necessary to resolve this domestic abuse problem (list or describe what relief is necessary):

____________________________________________________

___________________________________________________.

7. 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 to complete two other forms (Forms 4-961A and 4-961B) 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.

[ ] 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:

HomeWorkMessage

__________________________________________

8. NOTICE TO RESPONDENT

[ ]A.I have not told respondent that I am filing a petition to ask the court for an order of protection because I believe irreparable harm would result if I told respondent before coming to court. (Describe what might happen to you or what you are afraid might happen if the respondent knew you were asking for a court order of protection.). _______________________________

__________________________________________________________________

_______________________________________________________________.

[ ]B.I have told respondent that I am filing this petition.

9. 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:

_________________________ (social security number)

_________________________ (date of birth)

_________________________ (home telephone number) _________________________ (work address)

_________________________ (work telephone number).

B. Is respondent in jail? [ ] yes [ ] no

VERIFICATION

STATE OF NEW MEXICO }

COUNTY OF ________________ }

TRIBE OR PUEBLO __________ }

The petitioner was sworn and states: I have read this petition for order of protection from domestic abuse and it is true to the best of my knowledge and belief. I understand that I can be punished both civilly and criminally if any information in this petition is false.

__________________ __________________________

Date Signature of Petitioner

Signed and sworn before me on this ____ day of ______________, ______.

Notary public

_________________________________

My commission expires: _______________________.

USE NOTES

1. Petitioner should complete all information known by the petitioner.

2. This part must be completed if there are children. Section 40-10A-209 NMSA 1978 of the Uniform Child-Custody Jurisdiction Enforcement Act requires the first pleading of every custody action to give information under oath as to the child's present address, the places where the child has lived within the last (5) years and the names and present addresses of the persons with whom the child has lived during that period. If a child lives with you now, but you do not want respondent to know your address, do not put your current address here, but do fill out Forms 4-961A and 4-961B NMRA.

3. Use Notes 1 and 2 are to be printed on pre-printed forms published for use by pro se petitioners. This note and Use Note 4 should not be printed on the form. This form has been approved by the Supreme Court of New Mexico for use in the courts of this state and distribution pursuant to Section 40-13-3 NMSA 1978. Pre-printed pro se forms should include a lined blank page at the end of the form for use by the petitioner if the pre-printed form does not include adequate space for a complete answer to a question.

4. Section 40-13-3.1 NMSA 1978 provides that a victim in a domestic abuse case shall not be required to pay for "the issuance or service of a protection order". This has been construed to mean that a petitioner or counter-petitioner in a domestic abuse case is not required to pay a docket or other filing fees or fee for service of process.

[Approved, effective November 1, 1999 until July 1, 2001; approved, as amended, effective May 1, 2001; as amended, effective February 16, 2004.]