________________JUDICIAL DISTRICT COURT
COUNTY OF ___________________________
STATE OF NEW MEXICO

___________________________________________
Petitioner

v.                                    No. ____________

_______________________________________________
Respondent

1.    COURT ASSISTANCE REQUEST

[ ]    We will need an interpreter in _____________ to translate at hearings for [ ] me [ ] the petitioner.
[ ]    We will need ___________________________________________ (describe other request for special help).

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

    A.    The petitioner is:
        [ ]    my husband or [ ] my wife
        [ ]    my ex-husband or [ ] my ex-wife
        [ ]    the parent of my child(ren)
        [ ]    a family member _____________________ (describe the family relationship)
        [ ]    a person with whom I have had a continuing personal relationship _________________________________________ (describe the relationship).

    B.    The petitioner has the following weapons: __________________.

3.    CHILD(REN)2

    A.    List minor child(ren) of either party.

Name    Date of     Relationship of Child(ren)
    Birth     To You    To Petitioner
__________________    __________    __________    __________
__________________    __________    __________    __________
__________________    __________    __________    __________
__________________    __________    __________    __________
__________________    __________    __________    __________

    B.    List address and with whom the child(ren) are currently living. (List each child separately if child(ren) do not reside with same person.)
    _______________________________________________________________
    _______________________________________________________________
    ______________________________________________________________.

    C.    List each address where child(ren) have lived during the last 3 years. (List each child separately if child(ren) did not reside with same person.)
    _______________________________________________________________
    _______________________________________________________________
    ______________________________________________________________.

    D.    Does anyone else have physical custody of the child(ren) or claim to have custody or visitation rights? [ ] yes [ ] no
    If yes, complete the following for the child(ren):

     Child's name            Person 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 petitioner or the state:

Type of Case    Year Filed    Case Number     Where Filed
         (if known)    (if known)     (city and state)

________________    __________    ____________    ____________________
________________    __________    ____________    ____________________

5.    DOMESTIC ABUSE

    A.    The petitioner 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 petitioner not contact me, not abuse me and that the petitioner stay away from my residence, place of employment and or school.

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

            OR

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

    [ ]    C.    that the petitioner 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(ren) listed in this petition.

    [ ]    F.    that until the court hearing:
            [ ]    petitioner shall have the following contact with the child(ren): ______________________________________
                _____________________________________________.
            [ ]    petitioner shall have no contact with the child(ren).

    [ ]    G.    that the petitioner shall pay:
            [ ] support for the child(ren)
            [ ] support for me.

    [ ]    H.    that the petitioner 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 RESPONDENT (ME)
    (If you do not want the petitioner 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 PETITIONER 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
    _____________    _______________        ______________

8.    NOTICE TO PETITIONER

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

    [ ]    B.    I have told petitioner that I am filing this counter-petition.

9.    LOCATION OF PETITIONER

    A.    Petitioner may be found at:
    ___________________________________ (address)
    ___________________________________ (city) ___________________________________ (state and zip code)
    ___________________________________ (if in Indian Country, please name tribe or pueblo).

    Petitioner's:
    _________________________ (social security number)
    _________________________ (date of birth)
    _________________________ (home telephone number) _________________________ (work address)

    _________________________ (work telephone number).

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

STATE OF NEW MEXICO        }
COUNTY OF ________________    }
TRIBE OR PUEBLO __________    }

The respondent was sworn and states: I have read this counter-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 counter-petition is false.

__________________                __________________________
Date                            Signature of Respondent

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

Notary public

_________________________________

My commission expires: _______________________.

    1.    Respondent should complete all information known by the respondent.

    2.    This part must be completed if there are children. Section 40-10-10 NMSA 1978 of the Child Custody Jurisdiction 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 3 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 petitioner to know your address, do not put your current address here, but do fill out Forms 4-961A

and 4-961B.

    3.    Use notes 1 and 2 are to be printed on pre-printed forms published for use by pro se respondents. 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 respondent 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 May 1, 2001.]