STATE OF VERMONT SUPERIOR COURT Unit Plaintiff DOB V. Defendant FAMILY DIVISION Docket No. DOB Affidavit in Support of Request for Emergency Relief From Abuse/Neglect/Exploitation 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, subject to the penalties for perjury, I state the following facts, which are true to the best of my knowledge and belief, about the abusive, neglectful or exploitive treatment 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 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. (Please be specific. Where did it happen? Who else was there? Was a weapon involved?) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (attach a separate sheet of paper if necessary) 400-00852 � Affidavit in Support of Request for Abuse/Neglect/Exploitation (08/2016) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 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 ___________________ ___________________ ___________________ ___________________ ___________________ _____________________ _____________________ _____________________ _____________________ _____________________ __________________ __________________ __________________ __________________ __________________ Criminal Guardianship Probate Juvenile __________________ ___________________ ___________________ ___________________ ___________________ _____________________ _____________________ _____________________ ________________ __________________ __________________ __________________ I hereby swear or affirm that the information above is true to the best of my knowledge and belief. Dated _____________________________ ________________________________________ Signature of Plaintiff/Attorney/Interested Person Signed and sworn to before me: Date Signature of Notary Public Expiration Date NOTICE: This Affidavit will be served on Defendant with the Complaint for Relief from Abuse/Neglect/Exploitation 400-00852 � Affidavit in Support of Request for Abuse/Neglect/Exploitation (08/2016) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com