CONFIDENTIAL STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT COMPLAINT FOR AN ORDER OF PROTECTION FROM DOMESTIC VIOLENCE ­ 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 § 15-15-1, et seq., I request that the Family Court enter an order protecting me and/or _________________________________________________ from abuse. 1. My name is____________________________________________________. My present address is _____________________________________________________________________ _____________________________________. My telephone number is ___________________. 2. My former residence, which I have left to avoid abuse, is ____________________________ _____________________________________________________________________________. FC-54 (revised October 2014) Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT 3. I am the Parent/Guardian of the following child(ren) on whose behalf I am bringing this Complaint. 1. 2. 3. Date of Birth: Date of Birth: Date of Birth 4. 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: _______________________________________________________ 5. The relationship, between Plaintiff(s) and Defendant(s) is as follows. (Check and complete any that apply.) ______________________________________________________ is presently married to _____________________________________________________. ___________________________________________________________ was married to _____________________________________________________. I or ____________________________________________________ is the child or the parent of _____________________________________________________. I or _____________________________________________________ am/is/are a blood relative(s) or relative(s) by marriage of ________________________________________ ________________________________________________ who is my or the child(ren)'s __________________________________________________. I or _________________________________________________________________ and ______________________________________________________________ together are the legal parents of one (1) or more children. FC-54 (revised October 2014) Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT I or _________________________________________________________________ and ______________________________________________________________ have been in a substantive dating or engagement relationship within the past one (1) year and at least one of us is a minor. 6. On or about ______________________________________, 20____, I and/or the child(ren) suffered abuse when ____________________________________________________________ committed the following acts. (Check and complete any that apply.) Threatened and or harmed me and/or the child(ren) with the following weapon: _______________________________________________________________________. Attempted to cause me and/or the child(ren) physical harm. Caused me and/or the child(ren) physical harm. Placed me and/or the child(ren) in fear of imminent physical harm. Caused me and/or the child(ren) to engage involuntarily in sexual relations by force, threat of force, or duress. Stalked, cyberstalked, and/or harassed me and/or the child(ren). 7. I have no knowledge of the existence of other lawsuits between the parties, including actions for divorce, separate maintenance, custody of children, restraining orders, or other relief, and I have not sought a Protective Order from the Family Court or any other court for the same facts or circumstances alleged in this Complaint, except for the following: ________________________ ______________________________________________________________________________ _____________________________________________________________________________. 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. FC-54 (revised October 2014) Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT That ___________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________. I request that relief be ordered without notice because of the specific facts set forth in this Complaint and the attached affidavit. I and/or the children 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 Tem