400 - 00150C - Compliant for Relief from Abuse (08/2017) Page 1 of 2 STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. Plaintiff Date Of Birth Defendant Date Of Birth V. Complaint For Relief From Abuse Relationship of the Parties Spouses Family Member (describe relationship) Former Spouses Other (describe relationship) Persons who are or have been living together or sharing occupancy Persons who are or have been engaged in a sexual relationship Persons who are or have been dating Existing Court Order or Proceedings Is there an existing order or a pending court proceeding involving you, the Defendant, or the child(ren) in this Complaint? No Yes No Yes Divorce/Separation Civil Union Dissolution Relief from Abuse Criminal Parentage Guardianship Juvenile (DCF) State(s) County Attorney for Plaintiff Attorney for Defendant Facts 1. On (date) Defendant did the following to: Plaintiff Child( ren) Names of Child(ren) Attempted to cause or caused physical harm. Placed him/her/them in fear of imminent serious physical harm. Abused the child(ren) named above (physically injured or otherwise treated the child(ren) in a Stalked Plaintiff and/or child(ren) named above as defined in 12 V . S . A . 5131(6) on (date) and (date ) . Sexually assaulted Plaintiff and/or child(ren) named above as defined in 15 V . S . A . 5131( 5 ) 2. There is a danger of further abuse to: Plaintiff and/or child(ren) named above. 3. Defendant is incarcerated and has been convicted of one of the crimes specified in 15 V.S.A. 1103 (c)(1)(B). 4. Plaintiff has been/will be forced from residence and will be without shelter unless Defendant is ordered to leave the residence located at: . It is owned rented/leased in: Both Other 5. Defendant has a duty to support: Plaintiff and/or child(ren) named above. 6. Plaintiff Defendant is or has been a recipient of public assistance. American LegalNet, Inc. www.FormsWorkFlow.com 400 - 00150C - Compliant for Relief from Abuse (08/2017) Page 2 of 2 Request for Emergency Relief The Plaintiff requests that the court: order Defendant to not abuse Plaintiff and/or child(ren) named above. And from interferi ng with his/her/their personal liberty. order Defendant to refrain from stalking or sexually assaulting Plaintiff and/or child(ren) named above. order defendant to immediately leave the residence and to order sole possession to the Plaintiff. award temporary Parental Right and Responsibilities of the child(ren) named below to Plaintiff or to other persons. Name of Child Date of Birth Relationship to Plaintiff Relationship to Defendant order Defendant to refrain from cruelly treating the pet(s) of the parties or the pet(s) of the child(ren) named above . ordered Defendant to remain feet away from Plaintiff and/or child(ren) named above . order that Defendant may not contact Plaintiff and/or child(ren) named above in any way. Other: Request for Final Order The Plaintiff requests that the cou rt: order Defendant to not abuse Plaintiff and/or child(ren) named above. And from interfering with his/her/their personal liberty. order Defendant to refrain from stalking or sexually assaulting Plaintiff and/or child(ren) named above. order defendant to immediately leave the residence and to order sole possession to the Plaintiff. award temporary Parental Right and Responsibilities of the child(ren) named below to Plaintiff or to other persons. Name of Child Date of Birth Relationship to Plaintiff Relationship to Defendant award temporary possession and control of any pet(s) owned b y the parties or by the child(ren) named above to the Plaintiff. order Defendant to remain feet away from Plaintiff and/or child(ren) named above . order that Defendant may not contact Plaintiff and/or child(ren) named above in any way. order temporary living expenses. or der temporary child support Other: Dated Signature of Plaintiff/Attorney American LegalNet, Inc. www.FormsWorkFlow.com