Extreme Risk Protection Order - Petition Page 1 of 4 (Aug 2019) IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF Case No: In the Matter of: EXTREME RISK PROTECTION ORDER PETITION Respondent and AFFIDAVIT IN SUPPORT (Ex Parte if Not Renewal) Renewal of Order I need an interpreter: Spanish Russian other: PETITION I am the Petitioner named in the Affidavit. I believe Respondent is at risk for suicide or causing harm to another person in the near future. I ask the court to grant an Extreme Risk Protection Order to prohibit Respondent from owning, possessing, or acquiring deadly weapons, and to order surrender of deadly weapons to a law enforcement agency. For Renewals only: An Extreme Risk Protection Order was issued for this Respondent on (date, if known): and is currently in effect. This Petition is to renew the existing Order for one year, effective immediately upon expiration of the existing Order. AFFIDAVIT Petitioner222s Information: Name: Relationship to Respondent: law enforcement officer (DPSST#: ) Information about Respondent: 1. Respondent222s Information: a. Name: b. Address: c. Phone number: d. State ID # (SID) if known: e. Name and address of any hospital or other institution where Respondent is now admitted on a temporary or permanent basis, or other facility where Respondent is or is known to stay: American LegalNet, Inc. www.FormsWorkFlow.com Extreme Risk Protection Order - Petition Page 2 of 4 (Aug 2019) I believe Respondent is a risk to self or others now or in the near future because: 2. Respondent has a history of suicide threats or attempts (explain): 3. Respondent has a history of acts of violence against other people (explain): 4. Respondent has a history of use of physical force (or attempts / threats to use physical force) against another person (explain): 5. Respondent has recently used controlled substances unlawfully (explain): 6. Respondent has a history of unlawfully or recklessly using, displaying, or brandishing a deadly weapon (explain): American LegalNet, Inc. www.FormsWorkFlow.com Extreme Risk Protection Order - Petition Page 3 of 4 (Aug 2019) 7. Respondent previously violated a Family Abuse Prevention Act (FAPA) Restraining Order (explain): 8. Respondent has acquired or attempted to acquire a deadly weapon within the past 180 days (explain): 9. Respondent has been convicted of the following crimes: a misdemeanor involving violence (ORS 166.470) stalking (ORS 163.732 or 163.750) or a similar offense in another jurisdiction domestic violence (ORS 135.230) driving under the influence of intoxicants (ORS 813.010 or 813.011) an offense involving cruelty to or abuse of animals 10. Other information: I prefer to appear at the hearing by electronic video transmission (remote appearance) and I will contact the court to arrange this American LegalNet, Inc. www.FormsWorkFlow.com Extreme Risk Protection Order - Petition Page 4 of 4 (Aug 2019) I hereby declare that the above statements are true to the best of my knowledge and belief. I understand they are made for use in court and I am subject to penalty for perjury. I want to testify directly to the judge instead of notarizing this Petition Date Signature Name (printed) Address City, State, ZIP Phone State of , County of Signed and sworn to (or affirmed) before me on (date) by (name) My commission expires: Signature of notarial officer Title (and rank, if military officer) American LegalNet, Inc. www.FormsWorkFlow.com