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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, place of employment and school.
[ ] B. (1) that the respondent shall immediately leave [ ] my [ ] our residence.
OR
[ ] (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(ren) listed in this petition.
[ ] F. that until the court hearing:
[ ] respondent shall have the following contact with the child(ren):
______________________________________________________________________.
[ ] respondent shall have no contact with the child(ren).
[ ] G. that the respondent shall pay:
[ ] support for the child(ren)
[ ] 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.
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 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
Respondent may be found at:
______________________________ (address)
______________________________ (city)
______________________________ (state and zip code)