Form 151m 8/14 Page 1 of 3 STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. Name In re: DOB Name DOB Name of person filing on behalf of child DOB City, State, Zip AFFIDAVIT IN SUPPORT OF COMPLAINT FOR CHILD In support of the claims made in my complaint and subject to the penalti es for perjury, I state the following facts to be true to the best of my knowledge and be lief . 1. The most recent incident that causes me to ask for an order happened on or about Date at Time in Town, State when Name of person did the following to the minor child named above : ( Describe what happened below. B e specific: What was the act or threat of violence? W here did it happen? W ho else was there? W as a weapon involved? W as the child or anyone else injured? W hat were the injuries? ) Attach a separate sheet if necessary 2. Is the incident described above the most serious incident involving the defendant? Yes No If your answer is No, please fill in the following information: The most serious incident that causes me to ask f or an order happened on Date at Time American LegalNet, Inc. www.FormsWorkFlow.com Form 151m 8/14 Page 2 of 3 in Town, State ( Describe what happened below. Please b e specific: What was the act or threat of violence? W here did it happen? W ho else was there? W as a weapon involved? W as the child or anyone else injured? W hat were the injuries? ) Attach a separate sheet if necessary 3. Other past incidents of serious violence or threats that sup p ort my request for an Order include: ( Be specific: for each incident state : W hen and where it ha ppened, who else was there, and details about any inju r ies resulting or weapons used. ) American LegalNet, Inc. www.FormsWorkFlow.com Form 151m 8/14 Page 3 of 3 Attach a separate sheet if necessary 4. Do you feel that the child named above is in immediate danger of further abuse from the defendant? Yes No Do you believe that the defendant poses a danger to other children in the household? Yes No If you checked yes to either question , please explain why. 5. Is there an existing order or a pending court proceeding inv olving you, the Defendant and /or the child named in the complaint? Yes No If yes, please fill in the information requested below: Type of Proceeding Name of Case Name of Court And State Docket Number And Date Filed Divorce/Separation Civil Union Dissolution Parentage Relief From Abuse Protection Order Criminal Guardianship Probate Juvenile NOTICE: This Affidavit will be served on Defendant with your Complaint. 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. 2472904. I hereby swear or affirm that the information above is true to the best of my knowledge and belief. Signature of Plaintiff Date Printed Name Signed and sworn before me: Date Signature of Notary Public Expiration Date American LegalNet, Inc. www.FormsWorkFlow.com