COMPLAINT FOR PROTECTION FROM ABUSE (G.L. c. 209A) Page 2 of 2 COURT USE ONLY ­ DOCKET NO. TRIAL COURT OF MASSACHUSETTS A. RELATED PROCEEDINGS. Is there any proceeding that the Plaintiff knows of or has participated in which is pending or has been concluded in any Court in the Commonwealth or any other state or country involving the care or custody (including any care & protection or guardianship actions) of the child or children of the parties? YES NO If Yes, the Plaintiff shall complete and file with this Complaint an Affidavit Disclosing Care or Custody Proceedings as required by Trial Court Uniform Rule IV, and provide copies of documents required by the Rule. This Affidavit and related information are available from the office of the Clerk-Magistrate or Register of Probate of the Court. B. RELATED PROCEEDINGS. Are there any prior or pending court actions in any Court in the Commonwealth or in any other state or country involving the Plaintiff and the Defendant for paternity? YES NO C. CUSTODY. I request custody of the following minor child or children of the parties: NAME AGE ISSUES PERTAINING TO CHILDREN NAME AGE D. CONTACT WITH CHILDREN. I ask the Court to order the Defendant not to contact the following minor child or children unless authorized to do so by the Court: NAME AGE NAME AGE The specific reasons for this request are: ______________________________________________________________ I ask the Court to order the Defendant remain away from the following school(s) and day care(s) (list names and addresses): If the Plaintiff alleges that the Defendant has abused the above-named child or children, a separate Complaint may be filed on behalf of each child. ______________________________________________________________________________________________ ______________________________________________________________________________________________ E. VISITATION. If the Plaintiff is filing this Complaint in the Probate and Family Court, the Plaintiff may request a Visitation Order. Such Visitation Orders are not available in other Courts. Regarding visitation, I ask the Court to permit visitation. order no visitation between the Defendant and our minor child or children. permit visitation only at the following visitation center: ______________________________________________ (name) _____________________________, to be paid for by ______________________________________________. (name) permit only visitation supervised by ______________________________________________________________ at the following times: ________________________________________________________________________ (name) _____________________________, to be paid for by ______________________________________________. (name) order visitation only if a third party, __________________________________________________, picks up and drops off our minor child or children. other __________________________________________________________________________________________________________________________ F. TEMPORARY SUPPORT. I ask the Court to order the Defendant, who has a legal obligation to do so, to pay temporary support for any children in my custody. PLAINTIFFS SIGNATURE DATE FA-1A (5/15) X American LegalNet, Inc. www.FormsWorkFlow.com COURT COPY COMPLAINT FOR PROTECTION FROM ABUSE (G.L. c. 209A) Page 2 of 2 COURT USE ONLY ­ DOCKET NO. TRIAL COURT OF MASSACHUSETTS A. RELATED PROCEEDINGS. Is there any proceeding that the Plaintiff knows of or has participated in which is pending or has been concluded in any Court in the Commonwealth or any other state or country involving the care or custody (including any care & protection or guardianship actions) of the child or children of the parties? YES NO If Yes, the Plaintiff shall complete and file with this Complaint an Affidavit Disclosing Care or Custody Proceedings as required by Trial Court Uniform Rule IV, and provide copies of documents required by the Rule. This Affidavit and related information are available from the office of the Clerk-Magistrate or Register of Probate of the Court. B. RELATED PROCEEDINGS. Are there any prior or pending court actions in any Court in the Commonwealth or in any other state or country involving the Plaintiff and the Defendant for paternity? YES NO C. CUSTODY. I request custody of the following minor child or children of the parties: NAME AGE ISSUES PERTAINING TO CHILDREN D. CONTACT WITH CHILDREN. I ask the Court to order the Defendant not to contact the following minor child or children unless authorized to do so by the Court: NAME The specific reasons for this request are: ______________________________________________________________ I ask the Court to order the Defendant remain away from the following school(s) and day care(s) (list names and addresses): If the Plaintiff alleges that the Defendant has abused the above-named child or children, a separate Complaint may be filed on behalf of each child. ______________________________________________________________________________________________ ______________________________________________________________________________________________ E. VISITATION. If the Plaintiff is filing this Complaint in the Probate and Family Court, the Plaintiff may request a Visitation Order. Such Visitation Orders are not available in other Courts. Regarding visitation, I ask the Court to permit visitation. order no visitation between the Defendant and our minor child or children. permit visitation only at the following visitation center: ______________________________________________ (name) _____________________________, to be paid for by ______________________________________________. (name) permit only visitation supervised by ______________________________________________________________ at the following times: ________________________________________________________________________ (name) _____________________________, to be paid for by ______________________________________________. (name) order visitation only if a third party, __________________________________________________, picks up and drops off our minor child or children. other __________________________________________________________________________________________________________________________ F. I ask the Court to order the Defendant, who has a legal obligation to do so, to pay temporary support for any children in my custody. PLAINTIFFS SIGNATURE R P X O AGE IO T A B NAME NAME N AGE AGE TEMPORARY SUPPORT. DATE FA-1A (5/15) American Le