STATE OF MAINE DISTRICT COURT Location Docket No. Plaintiff: individually and on behalf of: COMPLAINT FOR PROTECTION FROM HARASSMENT (5 M.R.S.A. §§ 4651 et seq.) on behalf of: 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 American Indian or Alaskan Native Present street address, city and telephone number: ____________________________________ _____________________________________________________________________________ If different, mailing address:___________________________________________________ Unknown 3. I base my claim for protection from harassment on the following facts: Describe the harassment and include who committed it, when and where it occurred. (If additional space is needed attach another sheet.) 4. Are you aware of any matter currently pending in any Probate Court concerning any child named in this complaint? Yes No If yes, location of Probate Court: 5. You must choose either (a) or (b): (a) This claim involves an allegation of domestic or dating violence, sexual assault or stalking; OR (b) This claim does not involve an allegation of domestic or dating violence, sexual assault or stalking. 6. You must choose either (a) or (b): (a) I have attached to this Complaint a copy of the notice(s) issued by law enforcement pursuant to 17-A M.R.S. § 506-A to defendant to stop harassing me (or the person on whose behalf I am filing this Complaint). PA-006, Rev. 06/16 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com OR (b) I have not sought / obtained from law enforcement a notice to defendant to stop harassing me (or the person on whose behalf I am filing this Complaint) because: . MOTION FOR TEMPORARY ORDER (OPTIONAL) I am in immediate and present danger of physical abuse or extreme emotional distress from the defendant's conduct or my business property is in immediate and present danger of suffering substantial damage as a result of the defendant's actions because: I therefore request that a temporary order for protection from harassment be issued. REQUEST FOR RELIEF (you must select one or more of the options below) I ASK THE COURT TO: (a) Order the defendant to stop harassing me. (b) Order the defendant to have no contact with me, directly or indirectly. (c) Order the defendant not to enter my residence. (d) Order the defendant to refrain from repeatedly, and without reasonable cause, following me or being at, or in the vicinity of, my home, school, business or place of employment. (e) Order the defendant to refrain from interfering with my property. (f) Order the defendant to remove, destroy or return the private images or direct the removal, destruction or return of same, order the defendant to cease disseminating the private images and further order the defendant from any future dissemination of the private images. (g) Order the defendant to pay monetary compensation for losses that I have incurred as the result of the harassment. (h) Order the defendant to pay my attorney's fees and court costs and to order any other necessary and proper relief. (i) Order the defendant to refrain from destroying, transferring or tampering with my passport or other immigration document in the defendant's possession. Date: Signature of plaintiff Personally appeared the above named Plaintiff and signed and made oath to the truth of the statements in the above complaint, before me, Date: Clerk / Notary Public / Attorney at Law PA-006, Rev. 06/16 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com