Fill and Sign the Fillable Online Authorization for Reoccurring Creditdebit Form

400-00151N – Affidavit in Support of Relief from Abuse Complaint Notary (01/2017) Page 1 of 2 STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. Plaintiff Date O f Birth Defendant Date O f Birth V. Defendant’s Full Physical Address: _____________________________________________ ________________ Affidavit in Support of Relief from Abuse Complaint In support of the claims made in my complaint , I state the following facts to be true and correct to the best of my knowledge and belief. 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 i nvolved?) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (attach a separate sheet of paper if necessary) 400-00151N – Affidavit in Support of Relief from Abuse Complaint Notary (01/2017) Page 2 of 2 Other past incidents of serious violence or threats that support my re quest for an Order include: (Be specific. For each incident, state: When and where it happened, who else was t here, and details about any injuries result ing or weapons used.) ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ (attach a separate sheet of paper if necessary) Do you feel that you are in immediate danger of further abuse from the defendant? ☐ Yes ☐ No Is there an existing order or a pending court proceeding involving you, the defendant and/or the child/ren name in the complaint?? ☐ Yes ☐ No If YES, please fill in the information requested below: Type of Proceeding Name of Case Name of Court & State Docket Number & Date Filed 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 IMPRI SONMENT OR A FINE, OR BOTH AS PROVIDED BY 13 V.S.A §2904 I swear or affirm that the facts set forth in this petition are true a nd correct to the best of my knowledge and belief. Date: ___________________________ Signature: ___________________________________ _________ Printed Signature: ______________________________________ Signed and sworn to before me: Date: ___________________________ Expiration Date: ___________________ Signature of Notary: _____________________ _______________ NOTICE: This Affidavit will be served on Defendant with the Com plaint for Relief from Abuse