100-00247SA - Complaint for Order Against Sexual Assault (11/2018) Page 1 of 1 S TATE OF V ERMONT SUPERIOR COURT CIVIL DIVISION Unit Docket No. Plaintiff Defendant vs. COMPLAINT FOR ORDER AGAINST SEXUAL ASSAULT Plaintiff222s Information: Name: Date of Birth: Name(s) of minor child(ren): Defendant222s Information: Name: Date of Birth: Address: Relationship of the Parties: Married to each other Live in same residence (current or past) Divorced from each other Sexual relationship (current or past) Dating each other (current or past) Other (describe relationship) Family members (describe relationship) Other Civil/Probate/Juvenile/Criminal Court Proceedings or Orders Involving These Parties: Proceeding: Pending Order Existing Order Name of Court: County: State: Attorney: I. SEXUAL ASSAULT 1. On or about , the Defendant sexually assaulted the Plaintiff or the Plaintiff's child(ren) by doing one or more of the following: lewd and lascivious conduct lewd and lascivious conduct with a child sexual assault aggravated sexual assault use of a child in a sexual performance consenting to a sexual performance and Plaintiff was the victim of the offense 2. On , the Defendant was convicted of sexually assaulting the Plaintiff. II.REQUEST FOR RELIEFThe Plaintiff requests the Court: Order the Defendant to stay away from Other: I am asking for an emergency order before the Defendant is notified and a hearing is held because: The facts to support this request for protection order can be found on Plaintiff222s accompanying affidavit. Dated Signature of Plaintiff/Attorney American LegalNet, Inc. www.FormsWorkFlow.com