COMPLAINT FOR PROTECTION FROM ABUSE (G.L. c. 209A) Page 1 of 2 A BOSTON MUNICIPAL COURT DISTRICT COURT Name of Plaintiff (person seeking protection) COURT USE ONLY – DOCKET NO. PROBATE & FAMILY COURT SUPERIOR COURT ________________________ DIVISION Name of Defendant (person accused of abuse) F B my________________________ (relationship to Plaintiff) has filed this complaint for me. The Defendant is 18 or older. To my knowledge, the Defendant possesses the following D guns, ammunition, firearms identification card, and/or license to carry: Are there any prior or pending court actions in any state or country involving the Plaintiff and the Defendant for divorce, E annulment, separate support, legal separation or abuse prevention? No Yes If Yes, give Court, type of case, date, and (if available) docket no. Defendantʼs Alias, if any Sex: I am 18 or older. I am under the age of 18, and ________________________________________________, C I TRIAL COURT OF MASSACHUSETTS G M The Defendant and Plaintiff: are currently married to each other were formerly married to each other are not married but we are related to each other by blood or marriage; specifically, the Defendant is my F ______________________________________________ are the parents of one or more children are not related but live in the same household were formerly members of the same household are or were in a dating or engagement relationship. Does the Plaintiff have any children under the age of 18? No Yes H If Yes, the Plaintiff shall complete the appropriate parts of Page 2. On or about (dates) _____________________________________________________ I suffered abuse when the Defendant: attempted to cause me physical harm placed me in fear of imminent serious physical harm caused me physical harm caused me to engage in sexual relations by force, threat or duress THEREFORE, I ASK THE COURT: 1. to order the Defendant to stop abusing me by harming, threatening or attempting to harm me physically, or placing me in fear of imminent serious physical harm, or by using force, threat or duress to make me engage in sexual relations. 2. to order the Defendant not to contact me, unless authorized to do so by the Court. 3a. to order the Defendant to leave and remain away from my residence: See Plaintiff Confidential Information Form. If this is an apartment building or other multiple family dwelling, check here 3b. to order the Defendant to leave and remain away from my workplace: See Plaintiff Confidential Information Form. 3c. to order the Defendant to leave and remain away from my school: See Plaintiff Confidential Information Form. 4a. to order that my residential address not appear on the order. 4b. to order that my workplace address not appear on the order. 4c. to order that my school address not appear on the order. 5. to order the Defendant to pay me $__________________ in compensation for the following losses suffered as a direct result of the abuse: J __________________________________________________________________________________________________ 6. to order the Defendant, who has a legal obligation to do so, to pay temporary support to me. (You may not obtain a temporary Order from a Boston Municipal, District or Superior Court if there is a prior or pending Order for support from the Probate and Family Court.) 7. to order the relief requested on Page 2 of this Complaint pertaining to my minor child or children. 8. to order the following: ____________________________________________________________________________ 9. to order the relief I have requested, except for temporary support for me and/or my child(ren) and for compensation for losses suffered, without advance notice to the Defendant because there is a substantial likelihood of immediate danger of abuse. I understand that if the Court issues such a temporary Order, the Court will schedule a hearing within 10 court business days to determine whether such a temporary Order should be continued, and I must appear in Court on that day if I wish the Order to be continued. DATE PLAINTIFFʼS SIGNATURE X Please complete affidavit on reverse of this page This is a request for a civil order to protect the Plaintiff from future abuse. The actions of the Defendant may also constitute a crime subject to criminal penalties. For information about filing a criminal complaint, you can talk with the District Attorneyʼs Office for the location where the alleged abuse occurred. FA-1 (1/12) American LegalNet, Inc. www.FormsWorkFlow.com COURT COPY AFFIDAVIT Describe in detail the most recent incidents of abuse. The Judge requires as much information as possible, such as what happened, each personʼs actions, the dates, locations, any injuries, and any medical or other services sought. Also describe any history of abuse, with as much of the above detail as possible. On or about , 20 , the Defendant __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ If more space is needed, attach additional pages and check this box: I declare under penalty of perjury that all statements of fact made above, including those provided on P.1, Section E and P.2, Sections A and B of the Complaint form regarding prior and pending court actions, and in any additional pages attached, are true to the best of my knowledge. DATE SIGNED WITNESSED BY PLAINTIFFʼS SIGNATURE X ____________________________________________________________________________________ X ________________________________________________ PRINTED NAME OF WITNESS I have transcribed the above affidavit for the Plaintiff ______________________________________ ____________________________ Signature Print Name TITLE OF WITNESS Court Certified Interpreter Court Screened Interpreter Other _________________________ Remote Translation Via Telephone/Video American LegalNet, Inc. www.FormsWorkFlow.com PROTECTION FROM ABUSE INSTRUCTIONS TO THE PLAINTIFF Under chapter 209A of Massachusetts General Laws, Judges can make Orders to protect people from abuse by family or household members. These Orders will be recorded and enforced by law enforcement agencies. They are commonly called “Abuse Prevention Orders” or “Restraining Orders” or “209A Orders.” In an emergency that occurs after court hours or on weekends, you may ask your local police to put you in contact with a Judge. CHECKLIST OF FORMS COMPLAINT FORM: To request an Abuse Prevention Order, you must fill out a two-page Complaint form and any other appropriate forms. There is no filing fee. You are the “Plaintiff.” The person who you allege has abused you is the “Defendant.” Part C: If either you or the Defendant is under the age of 18, indicate that in Part C. The law provides that such cases are not open to public inspection and are available only to the Plaintiff, the Plaintiff’s attorney, the person under 18, or a parent or guardian of the person under 18. If you and the Defendant are both over 18, court records of this matter will generally be open to public inspection. If you have good reasons to ask the Judge to keep other parts of the court record confidential, you may file a written request (a “motion”) asking the Judge to do so. Usually, a general preference for privacy is not a sufficient reason to permit court records to be kept confidential. Part E: If you answer “Yes,” please bring with you to the courthouse any legal papers you have from any such court proceeding. Part J: In number 5, financial losses may include, but are not limited to, lost earnings or support, costs for restoring utilities, replacement costs for locks or personal property removed or destroyed, medical and moving expenses, and reasonable attorneys’ fees. AFFIDAVIT: On the back of the first (white) copy of the Complaint form is an affidavit where you should describe the abuse. When you are requesting relief after court hours, you must fill it out, unless a Judge indicates otherwise. PLAINTIFF CONFIDENTIAL INFORMATION FORM. Enter the appropriate information (addresses and telephone numbers). The information provided on this form is accessible only by the Plaintiff, those authorized by the Plaintiff, those authorized by statute and by court order. However, the Plaintiff's residential address and workplace address shall appear on the order and be accessible to the Defendant and the Defendant's attorney unless the Plaintiff specifically requests that the information be withheld from the order. The form is kept by the court but is not part of the public record. AFFIDAVIT DISCLOSING CARE OR CUSTODY PROCEEDINGS: If you have any children, check “Yes” in Part H on Page 1 of the Complaint form, complete the top and any other appropriate parts of Page 2, and follow instructions in Part A on Page 2 for completing an Affidavit Disclosing Care or Custody Proceedings. DEFENDANT INFORMATION FORM: This form describes the Defendant and where that person can be found. It will help law enforcement officers find that person to deliver the Order. American LegalNet, Inc. www.FormsWorkFlow.com