CONFIDENTIAL STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT COMPLAINT FOR AN ORDER OF PROTECTION FROM SEXUAL ABUSE 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 § 11-37.2-1, 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. 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 FC-58 (revised November 2014) 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. Name: __________________________________________________________________ Address: ________________________________________________________________ Telephone Number: _______________________________________________________ b. Name: __________________________________________________________________ Address: ________________________________________________________________ Telephone Number: _______________________________________________________ 4. On or about ______________________________________, 20____, I and/or the child(ren) suffered abuse when ____________________________________________________________ committed the following acts. (Check and complete any that apply.) Caused me and/or the child(ren) to engage involuntarily in sexual relations or contact by force, threat of force, or duress. Attempted to cause me or the child(ren) to engage involuntarily in sexual relations or contact by force, threat or force or duress; Stalked, cyberstalked and/or harassed me and/or the child(ren) with the intent to place me and/or the child(ren) in reasonable fear of bodily injury. 5. Specifically on the date(s) set forth on page 1, I and/or the child(ren) suffered the following sexual abuse: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________. 6. I have no knowledge of the existence of any other law suits between the adult 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-58 (revised November 2014) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL 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 _________________________________________ will suffer immediate and irreparable injury, loss, and/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 this Ex Parte Temporary Order for Protection from Sexual Abuse, 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 Order for Protection from Sexual Abuse and this Complaint will be dismissed. Name of the Plaintiff _____________________________________________________________________ Signature of the Plaintiff _____________________________________________________________________ Address: Telephone Number: Date: FC-58 (revised November 2014) Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL 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 not