Chapter 7A North Carolina General Assembly

NOTE TO PLAINTIFF:

Do not use this form if the relationship between you or the person on whose behalf you are filing this complaint and the defendant is current or former spouse; persons of the opposite sex who live or have lived together; have a child in common, are related as parent and child or grandparent and grandchild, are current or former household members, or are persons of the opposite sex who are in a dating relationship or have been in a dating relationship. In that situation use "Complaint And Motion For Domestic Violence Protective Order," AOC-CV-303. Check only the boxes below that apply and fill in blanks. Additional sheets may be attached.

The plaintiff resides The defendant resides The unlawful conduct occurred

2. a. I am a victim of unlawful conduct that occurred in North Carolina.

     b. The plaintiff is a minor or incompetent adult who is a victim of unlawful conduct that occurred in North Carolina, and I am a competent adult who resides in North Carolina and am filing this complaint on the victim's behalf.

3. The defendant was 16 years of age or older at the time of the unlawful conduct.

4. The defendant has committed nonconsensual sexual conduct against the plaintiff in that: (Give specific dates and describe in detail what happened.)

5. The defendant has followed on more than one occasion or otherwise tormented, terrorized, or terrified the plaintiff named above with the intent to place the plaintiff in reasonable fear for the plaintiff's safety or the safety of the plaintiff's immediate family or close personal associates or with the intent to cause, and which did cause, the plaintiff to suffer substantial emotional distress by placing the plaintiff in fear of death, bodily injury, or continued torment or terror in that: (Give specific dates and describe in detail what happened and how it placed the plaintiff in fear of safety or how it caused substantial emotional distress.)

Because Of These Acts Of Unlawful Conduct, The Plaintiff Requests That The Court Grant The Following Relief:

(Check only boxes that apply.)

1. A permanent no-contact order. (A permanent order cannot last longer than one year.)

2. A temporary no-contact order. (A temporary order cannot last longer than ten days.)

3. The temporary order to be issued ex parte (without notice to the defendant) because the plaintiff will suffer immediate injury, loss, or damage before the defendant can be heard in that: (explain)

AND

(If you checked Block 3 above, check a. or b. below.)

a. I certify that I have made the following efforts, if any, to give notice to the defendant and give the following reasons supporting why notice should not be required: (explain)

b. I certify that there is good cause to grant the remedy because the harm that the remedy is intended to prevent would likely occur if the defendant were given any prior notice of the request for relief in that: (Give specific reasons why harm would occur if prior notice were given to defendant.)

4. To order the defendant not to visit, assault, molest, or otherwise interfere with the plaintiff.

5. To order the defendant to stop stalking the plaintiff.

6. To order the defendant to cease harassment of the plaintiff

7. To order the defendant not to abuse or injure the plaintiff.

8. To order the defendant not to contact, by telephone, written communication, or electronic means, the plaintiff.

9. To order the defendant to refrain from entering or remaining present at the plaintiff's residence, school, place of employment, or other places specified.

(List Other Places Where You Want Defendant Ordered Not To Be)

10. Other: (specify)

VERIFICATION

I, the undersigned, being first duly sworn, say that I am the plaintiff in this action; that I have read the Complaint and Motion; that the matters and things alleged in the Complaint and Motion are true except as to those things alleged upon information and belief and as to those I believe them to be true and accurate.