400-00852 Affidavit in Support of Request for Abuse/Neglect/Exploitation (01/2017) Page 1 of 2 STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. Plaintiff D ate of B irth Defendant D ate of B irth V. A ffidavit in Support of Request for Emergency Relief F rom A buse /N eglect /E xploitation Pursuant to 33 V.S.A. Chapter 69 In support of the claims made in Plaintiff's request for Emergency Relief from Abuse/Neglect/Exploitation, I state the following facts, which are true to the best of my knowledge and belief, about the abusive, neglectful or exploitive t reatment and present situation: Specifically describe the facts that support the claim(s) of abuse/neglect/exploitation: 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 me and/or the minor children: (name) (attach a separate sheet of paper if necessary) Is the incident described above the most serious incident i nvolving 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. ( B e specific. Where did it happen? Who else was there? Was a weapon involved? ) (attach a separate sheet of paper if necessary) American LegalNet, Inc. www.FormsWorkFlow.com 400-00852 Affidavit in Support of Request for Abuse/Neglect/Exploitation (01/2017) Page 2 of 2 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) Is there an existing order or a pending court proceeding involving you or the defendant? Yes No If YES, please fill in the information requested below: Type of Proceeding Name of Case Name of Court & State Docket Number Divorce/Separation Civil Union Dissolution Parentage Relief from Abuse Protection Order Cri minal Guardianship Probate 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 247 2 9 0 4 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: Printe d Signature: Signed and sworn to before me: Date: Expiration Date: Signature of Notary : NOTICE: T his Affidavit will be served on Defendant with the Complaint for Relief from Abuse/Neglect/Exploitation American LegalNet, Inc. www.FormsWorkFlow.com