Form 248 Docket Number STATE OF VERMONT AFFIDAVIT IN SUPPORT OF REQUEST FOR ORDER AGAINST STALKING OR SEXUAL ASSAULT Pursuant to 12 V.S.A. 5133(a) Plaintiff Defendant VS. In support of my request for a protection order, subject to the penalties for perjury, I state the following facts to be true to the best of my knowledge and belief about the present situation: (Specifically describe the facts that support your complaint) Signature of Plaintiff Date Subscribed and sworn to before me. Signature of Notary Public Date Expiration Date NOTICE! This affidavit will be served on Defendant with the Complaint for Order Against Stalking or Sexual Assault. WARNING: MAKING FALSE STATEMENTS IN THIS AFFIDAVIT IS A CRIME SUBJECT TO A TERM OF IMPRISONMENT OR A FINE, OR BOTH AS PROVIDED BY 13 V.S.A. §2904. 7/06 SML Distribution: Original ~ Court; 1 Copy ~ Plaintiff; 1 Copy ~ Defendant; 1 Copy ~ File American LegalNet, Inc. www.FormsWorkflow.com