Superior Court of Washington For NO. __________________________________ _________ Petitioner DOB vs. __________________________________ _________ Respondent DOB Order to Surrender Weapon ORWPNP (CPL Restriction) ORWPN (No CPL Restriction) (Clerk's Action Required) This matter came on regularly before the court on a Petition for Surrender of Weapon. Based upon the petition, testimony, and the relevant case record, the court finds: By a preponderance of evidence that: Possession of a firearm or other dangerous weapon by the respondent presents a serious and imminent threat to public health or safety, or to the health or safety of any individual. By clear and convincing evidence that Respondent:  used, displayed, or threatened to use a firearm or other dangerous weapon in a felony. Has Previously committed an offense making him or her ineligible to possess a firearm under RCW 9.41.040. Other findings: __________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ That the relationship of the parties is: spouse or former spouse* parent of a common child * current or former cohabitant as intimate partner, including current or former registered domestic partner* current or former dating relationship stepparent or stepchild current or former cohabitant as roommate in-law parent or child blood relation other than parent or child And it is ordered that the respondent : (Strike out any restriction that does not apply)  Shall surrender all firearms and other dangerous weapons in your possession or control, including but not limited to, those listed in the table, below, and file proof of surrender within 5 business days of being served this order: Or to Surrender Weapon (ORWPNP,ORWPN) - Page 1 of 2 WPF DV-4.040 (06/2012) - RCW 9.41.800 American LegalNet, Inc. www.FormsWorkFlow.com Firearms and Other Dangerous Weapons Attach sheet if there are more to list. Surrender firearms and other dangerous weapons to: the Sheriff of __________________ County the Chief of Police of the City of _______________________________ respondent’s attorney, Name: __________________________ WSBA No. _________ Other, Name:__________________________________________________ Relationship to Respondent: _______________________  Shall surrender any concealed pistol license issued under RCW 9.41.070 to the same person or agency listed above.  Is prohibited from obtaining or possessing a firearm or other dangerous weapon or concealed pistol license. If the respondent has previously surrendered firearms, other dangerous weapons and concealed pistol license, they shall remain in the possession of the recipient until further order of the court. The Law Enforcement Officer serving this order is authorized to confiscate Respondent's weapons at the time of service. WACIC Entry 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 Police Department where petitioner lives which shall enter this order in the Washington Crime Information Center computer. Service _______________________ County Sheriff's Office or _______________________ City Police Department where respondent lives which shall personally serve the respondent with a copy of this order and shall promptly complete and return to this court proof of service. Respondent appeared in court. Additional service is not required. Dated _________________ at _________a.m./p.m. Presented by: Petitioner ___________________________________ Judge/Commissioner I acknowledge receipt of a copy of this order. Date ___________________________________ Respondent Date Or to Surrender Weapon (ORWPNP,ORWPN) - Page 2 of 2 WPF DV-4.040 (06/2012) - RCW 9.41.800 American LegalNet, Inc. www.FormsWorkFlow.com