400-00151MN 226 Affidavit in Support of Relief from Abuse Complaint for Child Notary (03/2019) Page 1 of 2 STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. Plaintiff Date Of Birth Defendant Date Of Birth V. Defendant222s Full Physical Address: Name of person filing on behalf of child: Date of Birth: Affidavit in Support of Relief from Abuse Complaint for Child In support of the claims made in my complaint, I state the following facts to be true and correct to the best of my knowledge and belief. The most recent incident that causes me to ask for an order happened on at (date) in the town of , in the state of (time) When did the following to the minor child named above: (name) (attach a separate sheet of paper if necessary) Is the incident described above the most serious incident involving the defendant? Yes No If you answered NO: The most serious incident that causes me to ask for an order happened on at (date) in the town of , in the state of . (time) Describe what happened below. (Be specific. Where did it happen? Who else was there? Was a weapon involved?) (attach a separate sheet of paper if necessary) Other past incidents of serious violence or threats that support my request for an Order include: (Be specific. For each incident, state: When and where it happened, who else was there, and details about any injuries resulting or weapons used.) (attach a separate sheet of paper if necessary) American LegalNet, Inc. www.FormsWorkFlow.com 400-00151MN 226 Affidavit in Support of Relief from Abuse Complaint for Child Notary (03/2019) Page 2 of 2 Do you feel that you are in immediate danger of further abuse from the defendant? Yes No Do you believe that the defendant poses a danger to other children in the household? Yes No If you answered YES to either questions, please explain why Is there an existing order or a pending court proceeding involving you, the defendant and/or the child/ren name in the complaint?? Yes No If YES, please fill in the information requested below: Type of Proceeding Name of Case Name of Court & State Docket Number & Date Filed Divorce/Separation Civil Union Dissolution Parentage Relief from Abuse Stalking/Sexual Assault Criminal Probate Guardianship Juvenile WARNING MAKING FALSE STATEMENTS IN THIS AFFIDAVIT IS A CRIME SUBJECT TO A TERM OF IMPRISONMENT OR A FINE, OR BOTH AS PROVIDED BY 13 V.S.A 2472904 I swear or affirm that the facts set forth in this petition are true and correct to the best of my knowledge and belief. Date: Signature: Printed Signature: Signed and sworn to before me: Date: Expiration Date: Signature of Notary: NOTICE: This Affidavit will be served on Defendant with the Complaint for Relief from Abuse American LegalNet, Inc. www.FormsWorkFlow.com