Fill and Sign the Relief from Abuse Neglect and Exploitation of a Vulnerable Form

400-00852N – Affidavit in Support of Request for Abuse/Neglect/Exploitation (01 /2017) Page 1 of 2 STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. Plaintiff D ate of B irth Defendant D ate of B irth V. A ffidavit in Support of Request for Emergency Relief F rom A buse /N eglect /E xploitation Pursuant to 33 V.S.A. Chapter 69 In support of the claims made in Plaintiff's request for Emergency Relief from Abuse/Neglect/Exploitation, I state the following facts, which are true to the best of my knowledge and belief, about the abusive, neglectful or exploitive t reatment and present situation: Specifically describe the facts that support the claim(s) of abuse/neglect/exploitation: 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 i nvolving 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. ( B e specific. Where did it happen? Who else was there? Was a weapon involved? ) ____________________________________________________________________________________ ____________________________________________________________________________________ ________________________________________________________________________ ____________ ____________________________________________________________________________________ ____________________________________________________________________________________ ______________________________________________________________________ ______________ (attach a separate sheet of paper if necessary) 400-00852N – Affidavit in Support of Request for Abuse/Neglect/Exploitation (01 /2017) Page 2 of 2 Other past incidents of serious violence or threats that support my request for an Order include: (Be specific. For each incident, state: When and where it happened, who else was there, and details about any injuries resulting or weapons used.) ___________________________________________________________________________________ ___________________________________________________________________________________ ______________________________ _____________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ (attach a separate sheet of paper if necessary) Is there an existing order or a pending court proceeding involving you or the defendant? ☐ Yes ☐ No If YES, please fill in the information requested below: Type of Proceeding Name of Case Name of Court & State Docket Number Divorce/Separation ___________________ ________ ___ __________ _______ _____ ______ Civil Union ___________________ _____________________ __________ ________ Dissolution Parentage ___________________ _____________________ __________________ Relief from Abuse ___________________ _____________________ __________________ Protection Order ___________________ _____________________ __________________ Cri minal __________________ ___________________ ________________ Guardianship ___________________ _____________________ __________________ Probate ___________________ _____________________ __________________ Juvenile ___________________ _____________________ __________________ WARNING MAKING FALSE STATEMENTS IN THIS AFFIDAVIT IS A CRIME SUBJECT TO A TERM OF IMPRISONMENT OR A FINE, OR BOTH AS PROVIDED BY 13 V.S.A § 2 9 0 4 I swear or affirm that the facts set forth in this petition are true and correct to the best of my knowledge and belief. Date: ___________________________ Signature: _________________ _______ ____________________ Printe d Signature: _________ _______ ________ __ ____________ Signed and sworn to before me: Date: _________ __________________ Expiration Date: ___________________ Signature of Notary : _________ __________ ________ _ ________ NOTICE: This Affidavit will be served on Defendant with the Complaint for Relief from Abuse/Neglect/Exploitation