400 - 00150CC - Compla i nt for Relief from Abuse On Behalf of a Child (0 1/2018 ) Page 1 of 3 STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. Name of Child Date Of Birth Defendant Date Of Birth (under 18 years of age) V. P (filing on behalf of child) Information: Name: Date of Birth: Relationship to C hild: Name : Street Address: Town: State: Zip: Complaint For Relief From Abuse On Behalf of a Child Relationship of the Defendant to the Child Parent/Guardian Family Member (describe relationship) Person who lives or has lived in the household with the child Child and defendant have or have had a dating relationship Other (describe relationship) Facts 1. On (date) Defendant: Abused the child named above (physically injured or otherwise treated the child named above in a life, health, development or welfare in jeopardy.) Defendant is a parent/legal guardian for the child named above and either (1) inflicted physical punishment out of anger, or (2) physically puni s hed the child named above in an excessive, unreasonable, or cruel manner. Stalked the child named above as defined in 12 V . S . A . 247 5131(6) . Sexually assaulted or sexually abused the child named above as defined in 15 V . S . A . 247 5131( 5 ) . Attempted to cause or caused physical harm to the child named above. Placed the child named above in fear of imminent serious physical harm. 2. There is danger of further abuse to the child other child(ren) in the household named below: Name of Child Date of Birth Relationship to P etitioner Relationship to Defendant 3. Defendant is incarcerated and has been convicted of one of the crimes specified in 15 V . S . A . 2471103(c)(1)(B) . 4. The child(ren) named above will be forced to leave his/her current residence and will be without shelter unless Defendant is ordered to leave the residence located at: . The residence is owned rented/leased in the name of the Petitioner filing on behalf of the child(ren) named above Defendant Both Other 5. Defendant has a duty to support the child(ren) named above. American LegalNet, Inc. www.FormsWorkFlow.com 400 - 00150CC - Compla i nt for Relief from Abuse On Behalf of a Child (0 1/2018 ) Page 2 of 3 Request for Emergency Relief The P etitioner requests that the c ourt: order Defendant not abuse child(ren) named above and not interfere with his/her/their personal liberty. order Defendant refrain from stalking or sexually a busing the child(ren) named above. order D efendant vacate immediately the residence (identified in #4 above) and sole possession be awarded to the P etitioner caring for the child(ren) named above . order Defendant refrain from cruelly treating the pet(s) of the parties or the pet(s) of the child(ren) named above . order Defendant stay feet away from the child(ren) named above in any way. order Defendant refrain from contacting the minor child(ren) named above in any way . award the Petitioner filing the complaint temporary Parental Right and Responsibilities for the child(ren) named below: Name of Child Date of Birth Relationship to Petitioner Relationship to Defendant Other: Request for Final Order Th e Petitioner requests that the c ourt: order Defendant not abuse child(ren) named above and not interfere with his/her/their personal liberty. order Defendant refrain from stalking or sexually abusing the child(ren) named above. order Defendant vacate immediately the residence (identified in #4 above) and sole possession be aw arded to the Petitioner caring for the child(ren) named above. order Defendant refrain from cruelly treating the pet(s) of the parties or the pet(s) of the child(ren) named above . order Defendant stay feet away from the child(ren) name d above in any way. order Defendant refrain from contacting the child(ren) named above in any way. a ward the Petitioner filing the complaint temporary Parental Right and Responsibilities for the child(ren) named below: Name of Child Date of Birth Relationship to Petitioner Relationship to Defendant order : at . order Exchanges of the child(ren) named above for parent child contac t take place a t supervised by . order Defendant not to take any regulated drug unless it is prescribed to Defendant by a physician or drink alcohol for at least 8 hours prior to a scheduled contact or during contac t with the child(ren) named above and that Petitioner may cancel scheduled contact if Defendant appears to be under the influence of intoxicating substances. American LegalNet, Inc. www.FormsWorkFlow.com 400 - 00150CC - Compla i nt for Relief from Abuse On Behalf of a Child (0 1/2018 ) Page 3 of 3 Request for Final Order - continued order Defendant not physically punish the child(ren) named above in any way. order Defendant pay temporary child support for the child(ren) named above. Other: The facts to support this request for relief from abuse Affidavit. Dated Signature of Petitioner / Attorney American LegalNet, Inc. www.FormsWorkFlow.com