FS-1 (Rev. 8.13.18)
Based on the following reasons, I believe that the Respondent poses a risk of causing bodily injury to self or others by having in
the Respondent's control firearms, rifles, shotguns, machine guns, stun guns or ammunition (provide as much detail as possible):
Date:
TRIAL COURT OF
MASSACHUSETTS
PETITION FOR EXTREME RISK
PROTECTION ORDER
G.L. c. 140, § 131R
Docket No.
Court Department: Division:
Boston Municipal Court District Court
Name of Petitioner (person seeking order): Name and Address of Respondent (person against whom order is sought):
I believe that the Respondent has a firearm identification card and/or license to carry firearms and controls, owns, or possesses
the following firearms, rifles, shotguns, machine guns, weapons, or ammunition:
I believe that these firearms, rifles, shotguns, machine guns, weapons, or ammunition is/are located:
My relationship to the Respondent is (check all that apply):
I am, or was married to the Respondent
I reside, or was residing, with the Respondent in the same household
I am, or was, related to the Respondent by blood or marriage
I have, or am having, a child in common with the Respondent
I am, or was, in a substantive dating relationship with the Respondent
I am the licensing authority of the municipality where the Respondent lives I am, or was, engaged to the Respondent
I believe that there is, either in Massachusetts or another jurisdiction (only check if applicable):
an abuse prevention order in effect against the Respondent
a harassment prevention order in effect against the Respondent
a pending legal action, specifically between me and the Respondent
if more space is needed, check this box and continue on the reverse side of this sheet
I declare under the pains and penalties of perjury that all statements of fact made in this Petition are true to the best of
my knowledge.
This is a request for a civil order directing the Respondent to surrender his or her firearms identification card and license to carry
firearms, firearms, rifles, shotguns, machine guns, stun guns and ammunition. If a judge issues an order in response to this
petition and the Respondent violates it, the Respondent may be subject to criminal penalties.
Petitioner's Signature
X
this is a renewal petition
FOR COURT USE ONLY:
Petition denied Petition denied because Respondent unlicensed (transmit Petition to Police Department where Respondent resides)
Renewal Petition denied No emergency order to issue, two party hearing scheduled for:
Petition denied because Petitioner ineligible (transmit Petition to Police Department where Respondent resides)
