________________JUDICIAL DISTRICT COURT
COUNTY OF ___________________________
STATE OF NEW MEXICO
STATE OF NEW MEXICO ON BEHALF OF:
___________________________________________
Petitioner
v. No. ____________
_______________________________________________
Respondent
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) ____________________________
_____ 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.
Name Date of Relationship of Child
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) 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:
_________________________ (social security number)
_________________________ (date of birth)
_________________________ (home telephone number)
_________________________ (work address)
_________________________ (work telephone number).
B. Is respondent in jail? [ ] yes [ ] no
_____ Petitioner's initials
I SWEAR OR AFFIRM UNDER PENALTY OF PERJURY 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 IMPRIS0NMENT IF I MAKE A FALSE
STATEMENT IN THIS PETITION.
__________________ ____________________________________
Date Signature of petitioner
I swear or affirm under penalty of perjury 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
1. Complete all information known by the officer.
Section 40-13-3.1 NMSA 1978 provides that the
petitioner 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 the petitioner 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; as amended, effective
August 29, 2000; approved, effective May 1, 2001.]
Cross-references.
See Section 30-25-1 NMSA 1978 for crime of perjury.
See Section 40-13-3.2 NMSA 1978 which requires a sworn written statement setting
for the need for an emergency order.