400-00853 Certificate of Notice to Plaintiff by Interested Person (09/201) Page 1 of 1 Plaintiff DOB Defendant DOB V. Certificate of Notice to Plaintiff by Interested Person Pursuant to 33 V.S.A. Section 6936(b) I certify that I have given notice to Plaintiff of this action by: delivering a copy of the attached Complaint for Relief from Abuse/Neglect/Exploitation at Other: Dated Signature of Plaintiff Receipt of Notice by Plaintiff I have received a copy of the Complaint for Relief f rom Abuse/Neglect/Exploitation. I wish to purs ue the Complaint for Relief f rom Abuse/ Neglect /Exploitation . I do not wish to purs ue the Complaint for Relief f rom Abuse/Neglect/ Exploitation . Plaintiff is unable to sign for receipt of notice because: Dated Interested Person STATE OF VERMONT SUPERIOR COURT Unit FAMILY DIVISIONDocket No. American LegalNet, Inc. www.FormsWorkFlow.com