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400 -00150C - Compliant for Relief from Abuse (08/2017) Page 1 of 2 STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. Plaintiff Date Of Birth Defendant Date Of Birth V. Defendant’s Full Physical Address: _____________________________________________________________ Complaint For Relief From Abuse Relationship of the Parties ☐ Spouses ☐ Family Member (describe relationship) __________________ ☐ Former Spouses ☐ Other (describe relationship) __________________ ☐ Persons who are or have been living together or sharing occupancy ☐ Persons who are or have been engaged in a sexual relationship ☐ Persons who are or have been dating Existing Court Order or Proceedings Is there an existing order or a pending court proceeding involving you, the Defendant, or the child(ren) in this Complaint? No Yes No Yes Divorce/Separation ☐ ☐ Civil Union Dissolution ☐ ☐ Relief from Abuse ☐ ☐ Criminal ☐ ☐ Parentage ☐ ☐ Guardianship ☐ ☐ Juvenile (DCF) ☐ ☐ State(s) __________________________________ County ________________________________ Attorney for Plaintiff _______________________ Attorney for Defendant ______________________ Facts 1. ☐ On (date) __________ Defendant did the following to: ☐ Plaintiff ☐ Child( ren) Names of Child(ren) ____________________ ____________________ ____________________ ☐ Attempted to cause or caused physical harm. ☐ Placed him/her/them in fear of imminent serious physical harm. ☐ Abused the child(ren) named above (physically injured or otherwise treated the child(ren) in a manner which placed the child(ren’s) life, health, development or welfare in jeopardy.) ☐ Stalked ☐ Plaintiff and/or ☐ child(ren) named above as defined in 12 V .S.A. 5131(6) on (date) __________ and (date ) __________. ☐ Sexually assaulted ☐ Plaintiff and/or ☐ child(ren) named above as defined in 15 V.S.A. 5131( 5) 2. ☐ There is a danger of further abuse to: ☐ Plaintiff and/or ☐ child(ren) named above. 3. ☐ Defendant is incarcerated and has been convicted of one of the crimes specified in 15 V.S.A. 1103 (c)(1)(B). 4. ☐ Plaintiff has been/will be forced from residence and will be without shelter unless Defendant is ordered to leave the residence located at: ___ __________________________________________. It is ☐ owned ☐ rented/leased in: ☐ Plaintiff’s name ☐ Defendant’s name ☐ Both ☐ Other 5. ☐ Defendant has a duty to support: ☐ Plaintiff and/or ☐ child(ren) named above. 6. ☐ Plaintiff ☐ Defendant is or has been a recipient of public assistance. 400 -00150C - Compliant for Relief from Abuse (08/2017) Page 2 of 2 Request for Emergency Relief The Plaintiff requests that the court: ☐ order Defendant to not abuse ☐ Plaintiff and/or ☐ child(ren) named above. And from interferi ng with his/her/their personal liberty. ☐ order Defendant to refrain from ☐ stalking or ☐ sexually assaulting ☐ Plaintiff and/or ☐ child(ren) named above. ☐ order defendant to immediately leave the residence and to order sole possession to the Plaintiff. ☐ award temporary Parental Right and Responsibilities of the child(ren) named below to Plaintiff or to other persons. Name of Child Date of Birth Relationship to Plaintiff Relationship to Defendant __ __ _______________ __ ______ _________ ___________________ _____________________ _____________________ _______________ ___________________ _____________________ _____________________ _______________ ___________________ _____________________ ☐ order Defendant to refrain from cruelly treating ☐ the pet(s) of the parties or ☐ the pet(s) of the child(ren) named above . ☐ ordered Defendant to remain ____ feet away from ☐ Plaintiff and/or ☐ child(ren) named above . ☐ order that Defendant may not contact ☐ Plaintiff and/or ☐ child(ren) named above in any way. ☐ Other: _____________________________________________________________________________ Request for Final Order The Plaintiff requests that the cou rt: ☐ order Defendant to not abuse ☐ Plaintiff and/or ☐ child(ren) named above. And from interfering with his/her/their personal liberty. ☐ order Defendant to refrain from ☐ stalking or ☐ sexually assaulting ☐ Plaintiff and/or ☐ child(ren) named above. ☐ order defendant to immediately leave the residence and to order sole possession to the Plaintiff. ☐ award temporary Parental Right and Responsibilities of the child(ren) named below to Plaintiff or to other persons. Name of Child Date of Birth Relationship to Plaintiff Relationship to Defendant _____________________ _______________ ___________________ _____________________ _____________________ _______________ ___________________ ______________ _______ _____________________ _______________ ___________________ _____________________ ☐ award temporary possession and control of any pet(s) owned b y the parties or by the child(ren) named above to the Plaintiff. ☐ order Defendant to remain __ __ __ feet away from ☐ Plaintiff and/or ☐ child(ren) named above . ☐ order that Defendant may not contact ☐ Plaintiff and/or ☐ child(ren) named above in any way. ☐ order temporary living expenses. ☐ or der temporary child support ☐ Other: _____________________________________________________________________________ The facts to support this request for relief can be found on the Plaintiff’s accompanying affidavit. Dated _____________________________ _______________ _____ ____________________ Signature of Plaintiff/Attorney