Fill and Sign the Affidavit in Support of Request for Emergency Relief Form

STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Plaintiff Docket No. Date of Birth Defendant Date of Birth V. Affidavit in Support of Request for Emergency Relief From Abuse/Neglect/Exploitation Pursuant to 33 V.S.A. Chapter 69 In support of the claims made in Plaintiff's request for Emergency Relief from Abuse/Neglect/Exploitation, I state the following facts, which are true to the best of my knowledge and belief, about the abusive, neglectful or exploitive treatment and present situation: Specifically describe the facts that support the claim(s) of abuse/neglect/exploitation: The most recent incident that causes me to ask for an order happened on ___________________ at (date) _______________ in the town of _______________________________, in the state of __________________ (time) When _________________________________ did the following to me and/or the minor children: (name) _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ (attach a separate sheet of paper if necessary) Is the incident described above the most serious incident involving the defendant? ☐ Yes ☐ No If you answered NO: The most serious incident that causes me to ask for an order happened on ___________________ at (date) _______________ in the town of _______________________________, in the state of _____________. (time) Describe what happened below. (Be specific. Where did it happen? Who else was there? Was a weapon involved?) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (attach a separate sheet of paper if necessary) 400-00852 – Affidavit in Support of Request for Abuse/Neglect/Exploitation (01/2017) Page 1 of 2 Other past incidents of serious violence or threats that support my request for an Order include: (Be specific. For each incident, state: When and where it happened, who else was there, and details about any injuries resulting or weapons used.) ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ (attach a separate sheet of paper if necessary) Is there an existing order or a pending court proceeding involving you or the defendant? ☐ Yes ☐ No If YES, please fill in the information requested below: Type of Proceeding Name of Case Name of Court & State Docket Number Divorce/Separation Civil Union Dissolution Parentage Relief from Abuse Protection Order ___________________ ___________________ ___________________ ___________________ ___________________ _____________________ _____________________ _____________________ _____________________ _____________________ __________________ __________________ __________________ __________________ __________________ Criminal __________________ ___________________ ________________ Guardianship Probate Juvenile ___________________ ___________________ ___________________ _____________________ _____________________ _____________________ __________________ __________________ __________________ WARNING MAKING FALSE STATEMENTS IN THIS AFFIDAVIT IS A CRIME SUBJECT TO A TERM OF IMPRISONMENT OR A FINE, OR BOTH AS PROVIDED BY 13 V.S.A §2904 I hereby swear under penalty of perjury that the information above is true and correct to the best of my knowledge and belief. Dated _____________________________ ________________________________________ Signature of Plaintiff/Attorney/Interested Person _____________________________________ Print Name NOTICE: This Affidavit will be served on Defendant with the Complaint for Relief from Abuse/Neglect/Exploitation 400-00852 – Affidavit in Support of Request for Abuse/Neglect/Exploitation (01/2017) Page 2 of 2