Fill and Sign the Petition for an Extreme Risk Form

Petition for an Extreme Risk Protection Order (PT) - Page 1 of 5 XR 101 (07/ 2019 ) – RCW 7.94.030. _________________ Court of Washington For _____________________ County Petitioner vs. Respondent DOB No . ___________________ Petition for an Extreme Risk Protection Order (PT) General Information 1.A [ ] I am a family or household member of the respondent. My relationship with the respondent is (check all that apply): [ ] Spouse or former spouse [ ] Blood relation other than parent or child [ ] Parent of a child in common [ ] Current or former legal guardian [ ] Current or former domestic partner [ ] Stepparent or stepchild [ ] Current or former cohabitant within the [ ] Parent or child past year [ ] In-law [ ] Current or former dating relationship 1.B [ ] I am filing on behalf of ___________________________ law enforcement agency. [ ] I have already notified the respondent’s family or household members and any known 3rd parties who may be at risk of violence; OR [ ] My agency will make a good faith effort to provide notice to them by [ ] telephone [ ] email [ ] in-person [ ] other _______________ within a reasonable period of time. 2. [ ] I reside in this county. [ ] I am filing on behalf of a law enforcement agency that is located in this county. [ ] The respondent resides in this county. 3. Describe below any firearms the respondent currently owns, possesses, has custody of , has access to, or controls. Type of firearm How many firearms? Where is the firearm kept? Date/time/place you last saw the firearm [ ] Handgun [ ] Shotgun / Rifle Petition for an Extreme Risk Protection Order (PT) - Page 2 of 5 XR 101 (07/ 2019 ) – RCW 7.94.030. [ ] Semi -Automatic Assault Rifle Check all the boxes that apply and describe below: [ ] Respondent has access to someone else’s firearm. [ ] Respondent expressed an intent to obtain a firearm. [ ] Respondent has unlawfully or recklessly used, displayed, or brandished a firearm. [ ] Respondent recently acquired a firearm. Describe: 4. Between the respondent and me: List any criminal or civil protection, restraining or no - contact orders, pending lawsuits, or other legal action: If you have more than three matters, list details on additional sheet. Case #1 Case #2 Case #3 Case Name Case Number Court/County/ State Type of Case Protected Person Was there any order violation? 5. Between the respondent and any other person: List any criminal or civil protection, restraining or no -contact orders: If you have more than three matters, list details on additional sheet. Case #1 Case #2 Case #3 Protected Person Case Number Court/County/ State Was there any order violation? Petition for an Extreme Risk Protection Order (PT) - Page 3 of 5 XR 101 (07/ 2019 ) – RCW 7.94.030. 6. Request for an Extreme Risk Protection Order [ ] I want a temporary extreme risk protection order effective immediately, without prior notice to respondent, that lasts up to 14 days, or until the court hearing : These are the specific facts known to me that cause me to believe the respondent poses a sign ificant danger in the near future of causing personal injury to self or others by having custody or control, purchasing, possessing, accessing, or receiving firearms. More detailed information is provided in the Statement in section 7. ___________________ _______________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________ ________________________ __________________________________________________________________________ _________________________________________________________________________. After a hearing, where the respondent has a right to be present, I want the c ourt to issue an Extreme Risk Protection Order that lasts for one year : After the hearing, I want the court to issue an Extreme Risk Protection Order that lasts for one year because the respondent poses a significant danger of causing personal injury to se lf or others by having custody or control, purchasing, possessing, or receiving a firearm. My statement below includes the respondent’s specific words, actions, or other facts that cause me to have a reasonable fear of future dangerous acts by respondent. 7. Statement To enter an Extreme Risk Protection Order, the court must find it more likely than not that the respondent poses a significant danger of causing personal injury to self or others by having custody or control, purchasing, possessing, accessing, or receiving a firearm. Complete all sections that apply . Attach additional pages, as needed. 8. Convictions or Arrests. Check all the boxes that apply and describe below: Respondent has been arrested or convicted of a: [ ] domestic violence crime. [ ] felony or violent crime. [ ] hate crime offense or malicious harassment (threats, physical injury or property damage based on the victim’s race, color, religion, ancestry, national origin, gender, sexual orientation, gender expression or identity, or mental, physical, or sensory disability ). Describe on the next page. Include location, court name, and case number, if known. Petition for an Extreme Risk Protection Order (PT) - Page 4 of 5 XR 101 (07/ 2019 ) – RCW 7.94.030. 9. Violence and Threats : Check each box that applies and explain below. [ ] Respondent has recently committed or threatened violence against self or others, whether or not respondent had a firearm. [ ] 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. [ ] Respondent has a history of use, attempted use, or threatened use of physical force against another person. [ ] Respondent has a history of stalking another person. Explain: Date/When Describe what happened. 10. Respondent’s behavior Describe any behaviors by the respondent that present an imminent threat of harm to self or others. Petition for an Extreme Risk Protection Order (PT) - Page 5 of 5 XR 101 (07/ 2019 ) – RCW 7.94.030. 11. Corroborated evidence of respondent’s alcohol or controlled substance abuse. Describe any evidence and attach any documents corroborating (supporting) the respondent’s abuse of alcohol, legal or illegal drugs. 12. Other important information that you think will help the court make a decision. 13. You must provide an address where you can be served with legal documents. Chose ONE option , then write the address in the line below: [ ] I can be served with legal documents at the address below: OR [ ] Disclosing my residential address would risk harm to me or a member of my family or household. I can be served with legal documents at the alternate address below: OR [ ] I am filing on behalf of a law enforcement agency. Service can be made at the law enforcement agency address listed below: Address: ______________________________________________________________________ ______________________________________________________________________________ I declare under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Dated: at , Washington. Signature of Petitioner Print Name and if Law enforcement Badge No.