STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT COMPLAINT FOR AN ORDER OF PROTECTION FROM DOMESTIC VIOLENCE Plaintiff Civil Action File Number Defendant 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 ____________________________ _____________________________________________________________________________. 3. The name(s) and present address(es) of the person(s) causing the abuse are: a. Name: __________________________________________________________________ b. Address: ________________________________________________________________ c. Telephone Number: _______________________________________________________ FC-53 (revised October 2014) Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT 4. 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 _____________________________________________________ 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. 5. On or about ______________________________________, 20____, I suffered abuse when __________________________________________________________________ committed the following acts. (Check and complete any that apply.) Threatened and or harmed me with the following weapon: _________________________ _______________________________________________________________________. Attempted to cause me physical harm. Caused me physical harm. Placed me in fear of imminent physical harm. Caused me to engage involuntarily in sexual relations by force, threat of force, or duress. Stalked, cyberstalked, and/or harassed me. 6. 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: ________________________ ______________________________________________________________________________ _____________________________________________________________________________. FC-53 (revised October 2014) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT 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 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 Temporary Order of Protection from Domestic Violence, 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 scheduled hearing date, the Ex Parte Temporary Order of Protection from Domestic Abuse and this Complaint will be dismissed. Name of the Plaintiff _____________________________________________________________________ Signature of the Plaintiff _____________________________________________________________________ Address: Telephone Number: Date: FC-53 (revised October 2014) Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT 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: ____________________________________ My commission expires: ____________________________ Notary identification number: ________________________ ATTORNEY CERTIFICATE Rhode Island Bar Number: /s/ ______________________________________________________ Attorney for the Plaintiff Office Telephone Number: Date: FC-53 (revised October 2