CONFIDENTIAL STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT COMPLAINT FOR A PROTECTIVE ORDER WHEN EITHER PARTY IS A JUVENILE Civil Action File Number PLAINTIFF, and as Parent/Guardian of ________________________________________________________ a. ______________________________________________________ b. ______________________________________________________ c. ______________________________________________________ ________________________________________________________ ________________________________________________________ DEFENDANT, and as Parent/Guardian of Murray Judicial Complex Newport County 45 Washington Square Newport, Rhode Island 02840-2913 (401) 841-8340 McGrath Judicial Complex Washington County 4800 Tower Hill Road Wakefield, Rhode Island 02879-2239 (401) 782-4111 Noel Judicial Complex Kent County 222 Quaker Lane Warwick, Rhode Island 02886-0107 (401) 822-6725 Garrahy Judicial Complex Providence/Bristol County One Dorrance Plaza Providence, Rhode Island 02903-2719 (401) 458-3200 Pursuant to G.L. 1956 § 8-10-3(g) and Rule 65 of the Rules of Procedure for Domestic Relations, I request that the Family Court enter an order protecting me and/or the children from immediate and irreparable injury, loss, or damage. 1. My name is ______________________________________________________. My present address is _____________________________________________________________________. My telephone number is ______________________. 2. I am the Parent/Guardian of the following child(ren) on whose behalf I am bringing this Complaint. 1. 2. 3. FC-31 (revised November 2014) Date of Birth: Date of Birth: Date of Birth Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT 3. The name(s) and present address(es) of the person(s) causing the abuse are: a. Parent/Guardian Name: ____________________________________________________ b. Address: ________________________________________________________________ c. Telephone Number: _______________________________________________________ d. Juvenile's Name: _________________________________________________________ e. Address: ________________________________________________________________ f. Telephone Number: _______________________________________________________ 4. The relationship, if any, between the Plaintiff(s) and the Defendant(s) is ______________________________________________________________________________ _____________________________________________________________________________. 5. I state under oath that immediate and irreparable injury, loss, or damage will result to me and/or the child(ren) if I do not obtain a temporary restraining order. 6. The Defendant and/or _______________________________________________________: (Check and complete any that apply) Caused me and/or _________________________________________________________ physical harm on or about _____________________________. Attempted to cause me and/or _______________________________________________ physical harm on the following date(s): Placed me and/or _______________________________________________________ in fear of imminent serious physical harm on the following date(s) Bullied me and/or _______________________________________________________ on the following date(s): FC-31 (revised November 2014) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT ________________________________________________________________________ ___________________________ on the following date(s) ________________________. 7. I have sought a Protective Order from any other judicial officer of the Rhode Island Family Court, or any other court, arising out of the same facts or circumstances alleged in this Complaint except for _____________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________. For these reasons, I respectfully request that the Family Court ORDER: (Check and complete any that apply.) That ___________________________________________________________________ be restrained and enjoined from contacting, assaulting, molesting, stalking, cyberstalking, cyberbullying, bullying, harassing, threatening, annoying, or otherwise interfering with me and/or ____________________________________________________________ at home, at school, on the street, or elsewhere. That ___________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________. I request that the relief be ordered without notice because of the specific facts set forth in this Complaint and the attached affidavit. I and/or the child(ren) will suffer immediate and irreparable injury, loss, or damage before notice can be served on the Defendant(s) and a hearing can be held on this Complaint. The Family Court will schedule a hearing no later than twenty-one (21) days after the Ex Parte Temporary Protective Order, if any, is entered. At the hearing, I will present evidence in support of my Complaint. I understand that if I fail to appear at the next scheduled hearing date, the Ex Parte Temporary Protective Order and this Complaint will be dismissed. FC-31 (revised November 2014) Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT Name of the Plaintiff _____________________________________________________________________ Signature of the Plaintiff _____________________________________________________________________ Address: Telephone Number: State of _______________________________ County of _____________________________ On this ________ day of ________________, 20____, before me, the undersigned notary public, personally appeared _____________________________________________________ personally known to the notary or proved to the notary through satisfactory evidence of identification, which was _________________________________________________, to be the person who signed above in my presence, and who swore or affirmed to the notary that the contents of the document are truthful to the best of his or her knowledge. Notary Public: ____________________________________