A COMPLAINT FOR PROTECTION FROM ABUSE (G.L. c. 209A) Page 1 of 2 Name of Plaintiff (person seeking protection) BOSTON MUNICIPAL COURT DISTRICT COURT COURT USE ONLY ­ DOCKET NO. PROBATE & FAMILY COURT Name of Defendant (person accused of abuse) SUPERIOR COURT TRIAL COURT OF MASSACHUSETTS ________________________ DIVISION B F Defendants Alias, if any C 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. I my________________________ (relationship to Plaintiff) has filed this complaint for me. The Defendant is 18 or older. I am 18 or older. I am under the age of 18, and ________________________________________________, G 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 Sex: M F H If Yes, the Plaintiff shall complete the appropriate parts of Does the Plaintiff have any children under the age of 18? No Yes Page 2. ______________________________________________ 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. 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: __________________________________________________________________________________________________ 6. to order the Defendant, who has a legal obligation to do so, to pay temporary support to me. 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. PLAINTIFFS SIGNATURE J DATE FA-1 (5/15) 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 Attorneys Office for the location where the alleged abuse occurred. American LegalNet, Inc. www.FormsWorkFlow.com X Please complete affidavit on reverse of this page COURT COPY A COMPLAINT FOR PROTECTION FROM ABUSE (G.L. c. 209A) Page 1 of 2 Name of Plaintiff (person seeking protection) BOSTON MUNICIPAL COURT DISTRICT COURT COURT USE ONLY ­ DOCKET NO. PROBATE & FAMILY COURT Name of Defendant (person accused of abuse) SUPERIOR COURT TRIAL COURT OF MASSACHUSETTS ________________________ DIVISION B F Defendants Alias, if any C 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. I my________________________ (relationship to Plaintiff) has filed this complaint for me. The Defendant is 18 or older. I am 18 or older. I am under the age of 18, and ________________________________________________, 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 _________________________________________________________________________________