Form XR121 "Temporary Extreme Risk Protection Order - Without Notice (Exrpo)" - Washington

What Is Form XR121?

This is a legal form that was released by the Washington Superior Court - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2020;
  • The latest edition provided by the Washington Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form XR121 by clicking the link below or browse more documents and templates provided by the Washington Superior Court.

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Download Form XR121 "Temporary Extreme Risk Protection Order - Without Notice (Exrpo)" - Washington

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Court of Washington
For
County
No
.
Temporary Extreme Risk Protection
Order - Without Notice
Petitioner
(EXRPO)
vs.
Next Hearing Date/Time: ____________
Court address:
Respondent
DOB
At:
Clerk's Action Required page 3
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 the 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 not violate this order. Only the court may
change this order and only after written application.
Respondent Identifiers
Respondent’s Distinguishing Features:
Sex
Race
Hair
____________________________________
_____________________________________
Height
Weight
Eyes
_____________________________________
_____________________________________
This temporary order expires at the end of the next hearing date listed above.
Respondent: You must immediately surrender all firearms and any concealed pistol licenses
listed below. If you have other firearms, you must surrender all of them also:
Attach additional sheet if there are more firearms to list.
Temporary Extreme Risk Protection Order-
Page 1 of 3
Without Notice (EXRPO)
XR 121 Mandatory (06/2020) RCW 7.94.050, .120
Court of Washington
For
County
No
.
Temporary Extreme Risk Protection
Order - Without Notice
Petitioner
(EXRPO)
vs.
Next Hearing Date/Time: ____________
Court address:
Respondent
DOB
At:
Clerk's Action Required page 3
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 the 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 not violate this order. Only the court may
change this order and only after written application.
Respondent Identifiers
Respondent’s Distinguishing Features:
Sex
Race
Hair
____________________________________
_____________________________________
Height
Weight
Eyes
_____________________________________
_____________________________________
This temporary order expires at the end of the next hearing date listed above.
Respondent: You must immediately surrender all firearms and any concealed pistol licenses
listed below. If you have other firearms, you must surrender all of them also:
Attach additional sheet if there are more firearms to list.
Temporary Extreme Risk Protection Order-
Page 1 of 3
Without Notice (EXRPO)
XR 121 Mandatory (06/2020) RCW 7.94.050, .120
Respondent: This order is valid until the date and time noted above. You are required to
surrender all firearms in your custody, control, or possession. 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 must surrender to the _______________________________________
(name of local law enforcement agency) all firearms in your custody, control, or possession and
any concealed pistol licenses issued to you under RCW 9.41.070 immediately. A hearing will
be held on the date and time noted above to determine if an extreme risk protection order
should be issued. Failure to appear at the hearing may result in a court making an order
against you that is valid for one year. You may seek the advice of an attorney as to any matter
connected with this order.
Based upon the evidence presented, the court finds reasonable cause to believe the
Respondent poses a significant danger of causing personal injury to self or others in the near
future by having in Respondent’s custody or control, purchasing, attempting to purchase,
possessing, accessing, or receiving firearms based upon (check all that apply):
a. [ ] Respondent has access to someone else’s firearm(s).
b. [ ] Respondent owns a firearm(s) or has 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.
g. [ ] Respondent violated a previous or current extreme risk protection order.
h. [ ] Respondent has been arrested for or convicted of a domestic violence crime.
i. [ ] Respondent has been arrested for or convicted of a felony offense or violent crime.
j. [ ] Respondent has been convicted of a hate crime 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. [ ] Respondent 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:
Temporary Extreme Risk Protection Order-
Page 2 of 3
Without Notice (EXRPO)
XR 121 Mandatory (06/2020) RCW 7.94.050, .120
Federal and Washington State Computer-Based System Data Entry
The clerk of the 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
appropriate federal and state computer-based criminal intelligence information systems per
RCW 7.94.110.
Service
The clerk of the court shall forward a copy of the petition, notice of hearing, and this order on
[ ]
or before the next judicial day to the _____________________ County Sheriff's Office or
________________________ City/Town Police Department where Respondent lives who
will serve a copy of the petition and this order on Respondent, remove all firearms and any
concealed pistol license, and file a return of service with the court
.
DOL Notification
The issuing court shall, within three judicial days after this order is issued, forward a copy of the
Respondent’s driver’s license, identicard, or comparable information along with the date of
issuance to DOL.
RESPONDENT: You must appear at the next hearing stated on page one of this order.
Dated: _______________ at _________ a.m./p.m. _________________________________
Judge/Commissioner
Presented by:
Signature of Petitioner/Attorney
WSBA No.
Print Name / Badge Number, if applicable
The Petitioner or Petitioner’s attorney must complete the Law Enforcement Information
– Extreme Risk Protection Order (LEIS), form XR 105.
Temporary Extreme Risk Protection Order-
Page 3 of 3
Without Notice (EXRPO)
XR 121 Mandatory (06/2020) RCW 7.94.050, .120
Page of 3