Fill and Sign the Defendants Information

STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Name of Child Docket No. Date Of Birth Defendant Date Of Birth (under 18 years of age) V. Petitioner’s (filing on behalf of child) Information: Name: __________________________________________ Date of Birth: ____________________________________ Relationship to Child: ______________________________ Defendant’s Information: Name: __________________________________________ Street Address: _________________________________________________________________________ Town: __________________________________ State: ____________ Zip: _____________ Complaint For Relief From Abuse On Behalf of a Child Relationship of the Defendant to the Child ☐ Parent/Guardian ☐ Family Member (describe relationship) ____________________________________ ☐ Person who lives or has lived in the household with the child ☐ Child and defendant have or have had a dating relationship ☐ Other (describe relationship) _______________________________________________________________ Facts 1. ☐ On (date) __________ Defendant: ☐ Abused the child named above (physically injured or otherwise treated the child named above in a manner which placed the child’s life, health, development or welfare in jeopardy.) ☐ Defendant is a parent/legal guardian for the child named above and either (1) inflicted physical punishment out of anger, or (2) physically punished the child named above in an excessive, unreasonable, or cruel manner. ☐ Stalked the child named above as defined in 12 V.S.A. §5131(6). ☐ Sexually assaulted or sexually abused the child named above as defined in 15 V.S.A. §5131(5). ☐ Attempted to cause or caused physical harm to the child named above. ☐ Placed the child named above in fear of imminent serious physical harm. 2. ☐ There is danger of further abuse to Name of Child _____________________ _____________________ _____________________ ☐ the child ☐ other child(ren) in the household named below: Date of Birth Relationship to Petitioner _______________ ___________________ _______________ ___________________ _______________ ___________________ Relationship to Defendant _____________________ _____________________ _____________________ 3. ☐ Defendant is incarcerated and has been convicted of one of the crimes specified in 15 V.S.A. §1103(c)(1)(B). 4. ☐ The child(ren) named above will be forced to leave his/her current residence and will be without shelter unless Defendant is ordered to leave the residence located at: _________________________. The residence is ☐ owned ☐ rented/leased in the name of the ☐ Petitioner filing on behalf of the child(ren) named above ☐ Defendant ☐ Both ☐ Other 5. ☐ Defendant has a duty to support ☐ the child(ren) named above. 400-00150CC - Complaint for Relief from Abuse On Behalf of a Child (01/2018) Page 1 of 3 Request for Emergency Relief The Petitioner requests that the court: ☐ order Defendant not abuse child(ren) named above and not interfere with his/her/their personal liberty. ☐ order Defendant refrain from stalking or sexually abusing the child(ren) named above. ☐ order Defendant vacate immediately the residence (identified in #4 above) and sole possession be awarded to the Petitioner caring for the child(ren) named above. ☐ order Defendant refrain from cruelly treating the pet(s) of the parties or the pet(s) of the child(ren) named above. ☐ order Defendant stay __________ feet away from the child(ren) named above in any way. ☐ order Defendant refrain from contacting the minor child(ren) named above in any way. ☐ award the Petitioner filing the complaint temporary Parental Right and Responsibilities for the child(ren) named below: Name of Child Date of Birth Relationship to Petitioner Relationship to Defendant _____________________ _______________ ___________________ _____________________ _____________________ _______________ ___________________ _____________________ _____________________ _______________ ___________________ _____________________ ☐ Other: ____________________________________________________________________________________ Request for Final Order The Petitioner requests that the court: ☐ order Defendant not abuse child(ren) named above and not interfere with his/her/their personal liberty. ☐ order Defendant refrain from stalking or sexually abusing the child(ren) named above. ☐ order Defendant vacate immediately the residence (identified in #4 above) and sole possession be awarded to the Petitioner caring for the child(ren) named above. ☐ order Defendant refrain from cruelly treating the pet(s) of the parties or the pet(s) of the child(ren) named above. ☐ order Defendant stay __________ feet away from the child(ren) named above in any way. ☐ order Defendant refrain from contacting the child(ren) named above in any way. ☐ award the Petitioner filing the complaint temporary Parental Right and Responsibilities for the child(ren) named below: Name of Child Date of Birth Relationship to Petitioner Relationship to Defendant _____________________ _______________ ___________________ _____________________ _____________________ _______________ ___________________ _____________________ _____________________ _______________ ___________________ _____________________ ☐ order Defendant’s contact with the child(ren) named above supervised by: _______________ at ____________. ☐ order Exchanges of the child(ren) named above for parent child contact take place at _____________________ supervised by _____________________________. ☐ order Defendant not to take any regulated drug unless it is prescribed to Defendant by a physician or drink alcohol for at least 8 hours prior to a scheduled contact or during contact with the child(ren) named above and that Petitioner may cancel scheduled contact if Defendant appears to be under the influence of intoxicating substances. 400-00150CC - Complaint for Relief from Abuse On Behalf of a Child (01/2018) Page 2 of 3 Request for Final Order - continued ☐ order Defendant not physically punish the child(ren) named above in any way. ☐ order Defendant pay temporary child support for the child(ren) named above. ☐ Other: _____________________________________________________________________________ The facts to support this request for relief from abuse are described in the Petitioner’s accompanying Affidavit. Dated _____________________________ 400-00150CC - Complaint for Relief from Abuse On Behalf of a Child (01/2018) ________________________________________ Signature of Petitioner/Petitioner’s Attorney Page 3 of 3