Fill and Sign the Complaint for Relief from Abuseneglectexploitation Vermont Judiciary Form

STATE OF VERMONT SUPERIOR COURT Unit FAMILY DIVISION Docket No. Complaint for Relief from Abuse/Neglect/Exploitation Pursuant to 33 V.S.A. Chapter 69 Plaintiff Information: Name: _________________________________________ Date of Birth: _____________________________ Interested Person’s Information: Name: _________________________________________ Date of Birth: _____________________________ Address: __________________________________________ Email Address: ____________________________ City/State/Zip: _____________________________________ Daytime Phone: ___________________________ I am: ☐ Agent ☐ Guardian ☐ Dept. of Aging/Disabilities Defendant Information: Name: _________________________________________ Date of Birth: _____________________________ Address: __________________________________________ Email Address: ____________________________ City/State/Zip: _____________________________________ Daytime Phone: ___________________________ Attorney Information: Name: ______________________________________________________________________________________ Address of Attorney: _________________________________ City/State/Zip: ____________________________ Phone Number: _____________________________________ Attorney is: ☐ for Plaintiff ☐ for Interested Person (To be completed by ‘interested person’ only) Plaintiff is 18 years of age or older and is a vulnerable adult because he/she: ☐ is a resident of a licensed long-term care facility; ☐ is a resident of a psychiatric hospital or psychiatric unit of a hospital; ☐ has been receiving personal care services for more than one month from a certified home health agency or from a person or organization that offers personal care; or ☐ regardless of residence or service received; is impaired due to brain damage, infirmities of aging, or a physical, mental or developmental disability that impairs his/her ability to provide for his/her own care without assistance or that impairs his/her ability to protect him/herself from abuse, neglect or exploitation. Plaintiff ☐ is capable of expressing Plaintiff’s wishes with respect to the Complaint or, ☐ is not capable of expressing Plaintiff’s wishes with respect to the Complaint because _________________________________________________________________________________ 400-00851 – Complaint for Relief from Abuse/Neglect/Exploitation (09/2016) Page 1 of 2 Plaintiff ☐ will attend the hearing ☐ will not attend the hearing. ☐ I request that a Guardian ad Litem be appointed because the Plaintiff is not capable of expressing an opinion with respect to the petition. On _______________________________, the Defendant ☐ Abused the Plaintiff, as “abuse” is defined by 33 V.S.A. Section 6902(1). ☐ Neglected the Plaintiff, as “neglected” is defined by 33 V.S.A. Section 6902(7). ☐ Exploited the Plaintiff, as “exploited” is defined by 33 V.S.A. Section 6902(6). The Plaintiff requests that the court enter an order which includes the following: ☐ an order that the Defendant refrain from abusing Plaintiff. ☐ an order that the Defendant refrain from neglecting Plaintiff. ☐ an order that the Defendant refrain from exploiting Plaintiff. ☐ an order that the Defendant immediately leave the household. The residence is: ☐ owned in: ☐ Plaintiff’s name only ☐ Defendant’s Name ☐ rented/leased ☐ Both Plaintiff’s & Defendant’s Name ☐ Other: __________________________________________________________________________ How will the vulnerable adult be cared for if the Petition is granted? ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ If immediate relief is requested complete the next section. Otherwise, skip to date & signature REQUEST FOR EMERGENCY RELIEF - MOTION FOR TEMPORARY ORDER Plaintiff will suffer serious and irreparable harm to Plaintiff’s physical health or financial interests unless ex parte relief is granted and therefore requests the Court to order: ☐ the Defendant to refrain from abusing the Plaintiff. ☐ the Defendant to refrain from neglecting the Plaintiff. ☐ the Defendant to refrain from exploiting the Plaintiff. ☐ the Defendant to immediately vacate the household. Location of Household: ____________________________________________________________ ☐ that the court clerk not release Plaintiff’s address to anyone except by Plaintiff’s written permission or Court order. ☐ Other: __________________________________________________________________________ The facts to support this request for Emergency relief can be found on Plaintiff’s accompanying affidavit. Dated _____________________________ 400-00851 – Complaint for Relief from Abuse/Neglect/Exploitation (09/2016) ___________________________________ Signature of Plaintiff/Attorney/Interested Person Page 2 of 2