STATE OF MAINE DISTRICT COURT Location Docket No. Plaintiff: individually and on behalf of: COMPLAINT FOR PROTECTION FROM ABUSE (19-A M.R.S. §§ 4001-4014) v. Defendant: on behalf of: 1. Plaintiff information: Full name: Gender: Female Male Date of birth: Present street address, city and telephone number: (list only your name if address is to be kept confidential and complete form PA-015, Affidavit for Confidential Address, which can be obtained from the clerk). If different, mailing address: 2. Defendant information: Full name: Gender: Female Male Date of birth: Race: White Black Asian or Pacific Islander Present street address, city and telephone number: American Indian or Alaskan Native Unknown If different, mailing address: 3. Plaintiff's former residence (if different from above), which plaintiff has left to avoid abuse: (street address, city, state): 4. Plaintiff's relationship to the defendant is: spouse; former spouse; father/mother of my child(ren); minor child of a household member; relative; former or present sexual partner; formerly or presently living together; dating partner; victim of defendant's sexual assault; victim of defendant's stalking; the victim of unauthorized dissemination of certain private images or Plaintiff is 60 years of age or older, or a dependent adult, or an incapacitated adult and defendant is plaintiff's extended family member (related by blood, adoption or marriage) or unpaid care provider; or victim of sex trafficking. If none of the above, describe relationship: 5. Plaintiff and defendant are the parents of the following child(ren). Name Date of Birth Gender Present Address List below where and with whom the child(ren) have lived with within the past 5 years. Name and present address of Dates child(ren) lived person child(ren) lived with with that person Town and State where child(ren) lived with that person 6. The person who has primary physical residence of the above-named child(ren) is 7. Plaintiff has not been involved in any way in, and has no information about, another court case in any state concerning the custody of the child(ren) except as follows: Divorce or Family Matter Action Probate Protective Custody Other (describe what kind of other case) 8. No one other than the parties has physical custody of the child(ren), or claims to have custody or visitation rights with respect to the child(ren), except as follows: 9. Check all of the following that apply: I am in immediate and present danger of abuse by the defendant, and I ask that the court issue a temporary order to protect me without prior notice to the defendant. My child(ren) are in immediate and present danger of abuse by the defendant, and I ask that the court issue a temporary order to protect my minor child(ren) without prior notice to the defendant. I am not asking for a temporary order. American LegalNet, Inc. www.FormsWorkFlow.com 10. Answer the following questions: Does defendant have access to possess in an intimidating, threatening or abusive way? If yes, please explain: ever used a firearm, muzzle loading firearm, bow or crossbow Yes No 11. I base my claim for protection from abuse on the following facts: Describe the abuse. State who committed the abuse, when it occurred and who was abused. 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