_______________ JUDICIAL DISTRICT COURT
COUNTY OF ___________________________
STATE OF NEW MEXICO

________________________________________
Petitioner

v.        

_________________________________________
Respondent

1.    I do not want my current address and telephone number to be made known to the respondent for the following reasons: ___________________________
    ______________________________________________________________
    ______________________________________________________________
    ______________________________________________________________
    ______________________________________________________________

2.    My current mailing address and telephone number are:

    ____________________________________
    (address)

    ____________________________________
    (city, state and zip code)

    My telephone numbers are:

    phone number        work phone        message phone
    ____________        ___________        _____________

3.    I ask the court not to disclose my current address and telephone number.

4.    I ask that if my request is granted, all process and papers be served on me by delivering them to the clerk of the court who shall serve me at my current address.

5.    I agree that if either my address or telephone number change during this lawsuit, I will immediately file another form like this one giving my new address or telephone number.

STATE OF NEW MEXICO            }
COUNTY OF ___________________    } ss
TRIBE OR PUEBLO _____________    }

    The petitioner was sworn and states: I have read the above information 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

                    ______________________________________
                    Petitioner's street address

                    ______________________________________
                    (City, state and zip code

    Signed and sworn before me on this _____ day of ____________, _____.

________________________            My commission expires:
Notary Public                    ________________________

I have reviewed this request
    [ ]    I recommend that the request be granted.
    [ ]    I recommend that the request be denied.

                        ________________________________
                        Signed

                        ________________________________
                        Title

                        ________________________________
                        Court's telephone number

[ ]    Request of petitioner is granted. The respondent shall serve all pleadings and other papers required to be served by filing them with the clerk who will note on the pleading or papers the date and manner of service. The clerk shall promptly serve such pleadings and papers on the petitioner, noting in the court file the date and manner of service upon petitioner.

[ ]    Request of the petitioner is denied. The petitioner shall place petitioner's name, address and phone number in the appropriate places on the petition prior to service of the petition upon the respondent.

                        ________________________________
                        District Judge

                        ________________________________
                        Date

[Approved, effective November 1, 1999 until July 1, 2001; approved, effective May 1, 2001.]

    The committee assumes that the district court has inherent power to grant requests of this type under compelling circumstances when petitioner demonstrates a reasonable basis to believe that the petitioner's physical safety or that of a household member would be threatened if petitioner's current address is made available to respondent. The form provides an alternative means by which respondent can serve pleadings and other papers on petitioner.