DC - 60 (revised October 16, 2017) Page 1 of 4 STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT DOMESTIC ABUSE COMPLAINT Plaintiff Civil Action File Number Defendant Attorney for the Plaintiff or the Plaintiff Address of the Defendant Plaintiff Murray Judicial Complex 2 nd Division District Court 45 Washington Square Newport, Rhode Island 02840 - 2913 (401) 841 - 8350 Noel Judicial Complex 3 rd Division District Court 222 Quaker Lane Warwick, Rhode Island 02886 - 0107 (401) 822 - 6750 McGrath Judicial Complex 4 th Division District Court 4800 Tower Hill Road Wakefield, Rhode Islan d 02879 - 2239 (401) 782 - 4131 Garrahy Judicial Complex 6 th Division District Court One Dorrance Plaza Providence, Rhode Island 02903 - 2719 (401) 458 - 5400 Pursuant to Title 8, Chapter 8.1 or Title 11, Chapter 37.2 of the General Laws of Rhode Island , I request that the court enter an order p rotecting me from abuse. 1. My full name, present street address, city, and telephone number are as follows: . I am an emancipated minor. I am a person eighteen (18) years of age or older. I am not related b y blood or marriage to the D efendant. 2. My former residence, which I have left to avoid abuse, is as follows (street address an d city): . American LegalNet, Inc. www.FormsWorkFlow.com DC - 60 (revised October 16, 2017) Page 2 of 4 STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT 3. My present former residence is a house My present former residence is an I own apartment Defendant owns * T here is no lease We jointly own My name is on the lease and the the lease and mine is not* Both our names are on lease *No order shall issue which would have the effect of compelling the D efendant who has the sole legal interest in a residence to vacate said residence. 4. The full name, present str eet address, city, and telephone number of the person causing me abuse (the defendant) are as follows: . 5. My relationship to the D efendant is as follows: Defendant and I together are not the legal parents of one (1) or more children. Defendant and I have resided together within the preceding three (3) years. Defendant and I are presently residing in the same living quarters. Defendant and I have had a substantive dating relationship within the preceding year. My relationship was created by the D the District Court under applicable statutes. 6. On or about , without cause or provocat ion, I suffered abu se when the D efendant: Atte mpted to cause me physical harm. Caused me physical harm . Placed me in fear of imminent serious physical harm. C aused me to engage involuntarily in sexual relations by force, threat of force, or duress. American LegalNet, Inc. www.FormsWorkFlow.com DC - 60 (revised October 16, 2017) Page 3 of 4 STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT Committed a sexual assault against me as defined in G.L. 1956 247247 11 - 37 - 1, 11 - 37 - 2, 11 - 37 - 4, 11 - 37 - 6, 11 - 37 - 8.1, 11 - 37 - 8.3, or 11 - 59 - 2. Committed stalking or cyber stalking against me. Spec ifically, the D efendant . 7. I ask that: The court order that the D efendant be restrained and enjoined from contacting, assaulting, molesting, or otherwise interfering with the P laintiff at home, on the street, or elsewhere. The court order the D efendant to immediately leave the household which is located at . The court orders that the D efendant be ordered to surrender physical possession of all Defendant restrained from purchasing, receiving, or attempting to purchase or receive any firearms while the protective order is in effect. 8. I certify that: To the best of my knowledge the Defendant is not an active member of the military service ; and/or To the best of my knowledge the Defendant is not a sworn peace officer as defined in G.L. 1956 247 12 - 7 - 21. I request that the above relief be ordered without notice because it clearly appears from specific facts shown by affidavit or by the verified complaint that I will suffer immediate and irreparable injury, loss, or damage before notice can be served an d a hearing had thereon. I understand that the courts will schedule a hearing no later than twenty - one (21) days after such order is entered on the question of continuing such temporary order. I have not sought a Protective Order from any other judicial officer of the District Court arising out of the same fa c ts or circumstances alleged in this complaint. American LegalNet, Inc. www.FormsWorkFlow.com DC - 60 (revised October 16, 2017) Page 4 of 4 STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT Name of the Plaintiff Signature of the Plaintiff State of County of On this day of , 20, before me, the undersigned notary public, personally appeared personally known to me or proved to me through satisfactory evidence of identification, which was , to be the person who signed above in my presence, and who swore or affirmed to me that the contents of the document are truthful to the best of h is or her knowledge. Notary Public: My commission expires: Notary identification number: ATTORNEY CERTIFICATE /s/ Attorney for the Plaintiff Rhode Island Bar Number: Date: Office Telephone Number: American LegalNet, Inc. www.FormsWorkFlow.com