400 - 00300 E xtreme Risk P etition (05/2018) Page 1 of 1 STATE OF VERMONT SUPERIOR COURT FAMILY DIVISION Unit Docket No. P etitioner Respondent Date Of Birth V. Respondent PETITION FOR EXTREME RISK PROTECTION ORDER Existing Court Order or Proceedings Is there an existing order or a pending court proceeding involving the Respondent in this petition ? No Yes No Yes R elief from Abuse Stalking or Sexual A ssault State(s) : County : Docket N umber: Facts On (date) Respondent did the following : i nflicted or attempted to inflict bodily harm o n another by his / her threats or actions has place d others in reasonable fear of physical harm to themselves by his / her actions or inactions h as presented a danger to persons in his /h er care has threatened or attempted suicide or serious bo dily harm Request for Emergency Relief The Petitioner requests that the C ourt prohibit the Respondent from purchasing, possessing, or r eceiving a dangerous weapon or having a dangerous weapon within his/her custody or control. Other: Request for Final Order The Petitioner requests that the C ourt prohibit the Respondent from purchasing, possessing, or r eceiving a dangerous weapon or having a dangerous weapon within his/her custody or control. Other: The facts to support this request for relief can be found on the Petitioner Dated Signature of Petitioner Printed Name of Petitioner Address of Petitioner American LegalNet, Inc. www.FormsWorkFlow.com