Fill and Sign the 5133 Requests for an Order Against Stalking or Sexual Assault Form

SUPERIOR COURT Unit Plaintiff STATE OF VERMONT CIVIL DIVISION Docket No. DOB Defendant DOB INTENT TO PURSUE OR WITHDRAW COMPLAINT Sexual Assault PURSUANT TO 12 V.S.A. §5133 Check Appropriate Box ☐ I understand my request for emergency relief has been denied. I hereby withdraw my request for a final order against sexual assault sought under 12 V.S.A. §5133. OR ☐ In spite of the fact that my request for emergency relief was denied, I intend to pursue my request for a final order against sexual assault order with 12 V.S.A. §5133. I request a hearing be set. Signature of Plaintiff Date IMPORTANT NOTICES INTENTION TO PURSUE OR WITHDRAW COMPLAINT FOR PROTECTION ORDER AGAINST SEXUAL ASSAULT IMPORTANT INFORMATION FOR PLAINTIFF If no request for a hearing is filed within five (5) business days from the date the denial order was issued, the request for a final order will be considered withdrawn. INFORMATION FOR PLAINTIFF AND DEFENDANT ABOUT REPRESENTATION BY AN ATTORNEY Although you may represent yourself at any hearing during these proceedings, you may wish to consult with or be represented by an attorney. If you hire an attorney to represent you, your attorney is required to tell the Court and the other party that they will be representing you. Both parties have the right to receive “notice” before any hearing that the opposing party will be represented by an attorney. The Vermont Rules of Civil Procedure require that such notice must be given to the opposing party or their attorney in person, by telephone, or in writing and it must be given far enough in advance of the hearing to permit them to hire an attorney too. If you do not provide such notice to the opposing party, and if the party without an attorney asks, the Court will postpone the hearing for a reasonable time to allow the unrepresented party to obtain an attorney. IMPORTANT INFORMATION FOR DEFENDANT At the hearing to be held on the date and time specified on the face of this notice, the Court will decide on whether to issue or deny a final order. After the hearing, an order may be issued, which may remain in effect for a defined period of time, which will be stated on the order. If you fail to appear at the hearing, an order may be issued against you granting the Plaintiff’s requests for relief as the Court deems appropriate. 100-00251SA – Intent to Pursue or Withdraw Complaint – Sexual Assault (07/2019) Page 1 of 2 RETURN OF SERVICE STATE OF VERMONT SUPERIOR COURT Unit CIVIL DIVISION Docket No. I personally served: (check all that apply) ☐ Complaint, Affidavit and Temporary Order ☐ Order to Modify/Extend/Vacate Order ☐ Temporary Order ☐ Extended Final Order ☐ Final Order ☐ Extended Temporary Order ☐ Court Service Information Sheet ☐ Denial of Emergency Relief Intent to Pursue Notice of hearing ☐ Amended/Modified Temporary Order ☐ Amended/Modified Final Order Upon ____________ by: Date:_______________ Time: ____________ ☐ AM ☐ PM Date Place:______________________________________ Officer’s Name, Title and Agency Officer’s Signature Acceptance of Service I hereby accept service of this order. Fees Date Signature Service Fee _ _ Miles X $0. per mile Total (please type or print name) 100-00251SA – Intent to Pursue or Withdraw Complaint – Sexual Assault (07/2019) Page 2 of 2