400 - 00 851 Complaint for Relief fr o m Abuse/Neglect/Exploitation (09 /201 6 ) Page 1 of 2 STATE OF VERMONT SUPERIOR COURT DIVISION Unit Docket No. Complaint for Relief from Abuse/Neglect/Exploitation Pursuant to 33 V.S.A. Chapter 69 Plaintiff Information: Name: Date of Birth: Information: Name: Date of Birth: Address: Email Address: City/State/Zip: Daytime Phone: I am: Agent Guardian Dept. of Aging/Disabilities Defendant Information: Name: Date of Birth: Address: Email Address: City/State/Zip: Daytime Phone: Attorney Information: Name : Address of Attorney: City/State/Zip: Phone Number: Attorney is: for Plaintiff for Interested Person interested person only) Plaintiff is 18 years of age or older and is a vulnerable adult because he/she: is a resident of a licensed long - term care facility; is a resident of a psychiatric hospital or psychiatric unit of a hospital; has been receiv ing personal care services for more than one month from a certified home health agency or from a person or organization that offers personal care; or regardless o f re sid ence or service received ; is impaired due to brain damage, infirmities of aging, or a physical, mental or developmental disability that impairs his/her ability to provide for his/her own care without assistance or that impairs his/her ability to protect hi m/herself from abuse , neglect or exploitation . Plaintiff American LegalNet, Inc. www.FormsWorkFlow.com 400 - 00 851 Complaint for Relief fr o m Abuse/Neglect/Exploitation (09 /201 6 ) Page 2 of 2 Plaintiff will attend the hearing will not atten d the hearing. I request that a Guardian ad Litem be appointed because the Plaintiff is not capable of expressing an opinion with respect to the petition. On , the Defendant The Plaintiff requests that the court enter an order which includes the following: an order that the Defendant refrain from abusing Plaintiff. an order that the Defendant refrain from neglecting Plaintiff. an order that the D efendant refrain from exploiting Plaintiff. an order that the Defendant immediately leave the house hold. The residence is: owned in: rented/leased Other: How will the vulnerable adult be cared for if the Petition is granted? If immediate relief is requested complete the next section. Otherwise, skip to date & signature REQUEST FOR EMERGENCY RELIEF - MOTION FOR TEMPORARY ORDER Plaintiff will suffer serious and irreparable harm to P parte relief is granted and therefore requests the Court to order: the Defendant to refrain from abusing the Plaint iff. the Defendant to refrain from neglecting the Plaintiff. the Defendant to refrain from exploiting the Plaintiff. the Defendant to immediately vacate the household. Location of Household : that the court clerk not release P P C ourt order. Other: The facts to support this request for E m ergency relief can be found on P . Dated Signature of Plaintiff/Attorney /Interested Person American LegalNet, Inc. www.FormsWorkFlow.com