Fill and Sign the Extreme Risk Protection Order Form

Extreme Risk Protection Order (XRPO, ORRXRPO) - Page 1 of 5 XR -141 ( 07/2019 ) – RCW 7.94.040, .120 Court of Washington For County No . Petitioner vs. Respondent DOB Extreme Risk Protection Order (XRPO) [ ] Renewal (ORRXRPO) Next Hearing Date/Time: ____________ Court address: At : Clerk's Action Required page 4 Warning to Respondent! You are prohibited from having a firearm in your custody or control, or from purchasing, possessing , accessing, or receiving any firearm. You must surrender any and all firearms including but not limited to firearms as described below . If you violate this order, you may be charged with a crime and you may not be able to have a firearm for at least five more years after this order expires. RCW 7.94.120. You have the sole responsibility to avoid or refrain from violating this order. Only the court may change this order and only after written application. Respondent’s Distinguishing Features: Respondent Ident ifiers ____________________________________ _____________________________________ _____________________________________ _____________________________________ Sex Race Hair Height Weight Eyes This one -year order expires on date: ______________ time : ______ a.m./p.m. Respondent: You must surrender all firearms and any concealed pistol license s listed below. If you have other firearms, you must surrender all of them also: Attach additional sheet if there are more firearms to list. Extreme Risk Protection Order (XRPO, ORRXRPO) - Page 2 of 5 XR -141 ( 07/2019 ) – RCW 7.94.040, .120 Respondent : This order will last until the date and time noted above. If you have not done so already, you must surrender to the ______________________________ (local law enforcement agency) all firearms in your custody, control, or possession and any concealed pistol license s issued to you under RCW 9.41.070 immediately. You may not have in your custody or control, purchase, possess, receive, or attempt to purchase or receive, a firearm while this order is in effect. You have the right to request one hearing to terminate this order every 12 -month period that this order is in effect, starting from the date of this order and continuing through any renewals. You may seek the advice of an attorney as to any matter connected with this order. Respondent: You must immediately surrender all firearms as follows: 1. Personally served : a. If this order is served by a law enforcement officer, immediately surrender all firearm(s) and any concealed pistol license s to the serving officer. b. If this order is served upon you by someone who is not a law enforcement officer, surrender the firearm(s) to the law enforcement agency listed in this order. Contact the law enforcement agency for directions on how to surrender immediately the firearm(s) and concealed pistol license. 2. Attended the hearing : If you attended the hearing where the court issued this order, surrender the firearm(s) and concealed pistol license s to the law enforcement agency listed in this order within 48 hours . Contact the law enforcement agency for directions o n how to surrender the firearms . 3. Service by publication/mail : If you were served a copy of this order by publication or by mail, surrender the firearm(s) and concealed pistol license (s) to the law enforcement agen cy listed in this order within 48 -hours of the date of service . Contact the law enforcement agency for directions on how to surrender the firearm(s) and concealed pistol license (s) . This Extreme Risk Protection Order is based upon the following findings : 1. Notice : Respondent received notice of this hearing by [ ] personal service [ ] publication [ ] mail. 2. Reasonable Cause : There is reasonable cause to believe that the respondent poses a significant danger of causing personal injury to himself/herself or to others in the future by having in respondent’s custody or control, purchasing, possessing, accessing, or receiving firearms; based upon (check all that apply on the following page) : a. [ ] Respondent has access to someone else’s firearm(s). b. [ ] Respondent expressed intent to obtain a firearm(s). c. [ ] Respondent has unlawfully or recklessly used, displayed, or brandished a firearm. d. [ ] Respondent recently acquired a firearm(s). e. [ ] Respondent violated a civil or criminal protection order, no -contact order or restraining order issued under chapter 7.90, 7.92, 10.14, 9A.46, 10.99, 26.50, or 26.52 RCW. f. [ ] Respondent was/is the subject of a previous or current extreme risk protection order. Extreme Risk Protection Order (XRPO, ORRXRPO) - Page 3 of 5 XR -141 ( 07/2019 ) – RCW 7.94.040, .120 g. [ ] Respondent violated a previous or current extreme risk protection order. h. [ ] Respondent has been arrested for or convicted of a domestic violence cr ime. i. [ ] Respondent has been arrested for or convicted of a felony offense or violent crime. j. [ ] Respondent has been convicted of a hate crime offense or malicious harassment under RCW 9A.36.080 . k. [ ] Respondent has recently committed or threatened violence against self or others, whether or not respondent had a firearm. l. [ ] Respondent has shown, within the past 12 months, a pattern of acts or threats of violence, which can include violent acts against self or others. m. [ ] Respond ent has a history of use, attempted use, or threatened use of physical force against another person. n. [ ] Respondent has a history of stalking another person. o. [ ] Respondent ’s behaviors present an imminent threat of harm to self or others. p. [ ] There is corroborative evidence of respondent’s abuse of [ ] alcohol or [ ] controlled substances. q. [ ] Other: . 3. Evaluation : The court has considered whether it is appropriate to order a behavioral health evaluation of the respondent. The court finds that conducting a behavioral health evaluation is [ ] appropriate [ ] not appropriate. [ ] Respondent : You must have a behavioral health evaluation completed by a qualified evaluator within ____ _____ days of this order. Pr oof of obtaining the evaluation must be filed with this court within _______ days of completion. [ ] While appropriate, the court is not ordering an evaluation for the following reasons: Federal and Washington State Computer -Based System Data Entry The clerk of court shall forward a copy of this order on the same day the court issues the order to the ___________________ County Sheriff's Office or _____________________ City/Town Police Department where respondent lives which shall enter this order into the available federal and state computer -based criminal intelligence information systems per RCW 7.94.110. Extreme Risk Protection Order (XRPO, ORRXRPO) - Page 4 of 5 XR -141 ( 07/2019 ) – RCW 7.94.040, .120 Service [ ] The respondent appeared in person. Additional service is not required . [ ] The respondent did not appear in person. [ ] The clerk of court shall forward a copy of this order on or before the next judicial day to the _____________________ County Sheriff's Office or ________________________ City/Town Police Department where res pondent lives who will serve a copy of this order on respondent and file a return of service with the court. [ ] The petitioner requested and shall arrange for private service of this order. Service may be done by a professional process server, or a pers on 18 or over who is not a party to this action, and who is responsible for filing the return of service with the court. [ ] The court previously ordered service by publication or mail, or the court finds that there are now reasons to allow such service. Therefore, the court orders service of this order on respondent by [ ] publication [ ] mail. DOL Notification The issuing court shall within 3 judicial days after this order issued, forward a copy of the respondent’s driver’s license or identicard, or c omparable information along with the date of issuance to DOL. Respondent : You must attend the hearing listed on page one of this order and show the court that you surrendered your firearm(s) and concealed pistol license. Dated: _______________ at _________ a.m./p.m. _________________________________ Judge/Commissioner I acknowledge receipt of a copy of this order. Signature of Respondent Print Name Signature of Respondent’s Attorney WSBA No. Print Name Signature of Petitioner/Attorn ey WSBA No. Print Name and Badge No., if applicable The petitioner or petitioner’s lawyer must complete the Law Enforcement Information – Extreme Risk Protection Order (LEIS) form , XR 105. NOTICES: To Petitioner : You may file a motion to ask the court to renew this one -year order. You may begin that process no sooner than 105 days prior to the date this order expires (see page 1). To Respondent : You may file a motion requesting the court to terminate this one -year order. You may make this request only once during the one year period of this order. To both parties : The court will consider any motion to terminate or renew this order only upon the filing of a written motion, the scheduling of a hearing and notic e to the other party. Extreme Risk Protection Order (XRPO, ORRXRPO) - Page 5 of 5 XR -141 ( 07/2019 ) – RCW 7.94.040, .120 Respondent: Read more information about surrender of weapons. Receipt : The law enforcement officer who receives your firearms will prepare a receipt with a list of the firearms. The law enforcement officer shall file the receipt with the court within 72 hours. The officer will give you a copy of the receipt to keep for your records. If someone else owns the firearms : If the law enforcement agency determines someone else is the lawful owner of the firearm(s), the agency will return the firearm to the lawful owner, if:  the firearm is removed from the respondent’s custody, control, and possession;  the lawful owner agrees to store the firearm in a way that respondent does not have access and control of the firearm; and  the owner does n ot otherwise unlawfully possess the firearm.