Form 247 Complaint for Order against Stalking or Sexual Assault County Docket Number Vermont Superior Court SELECT COUNTY Plaintiff's Name Defendant's Name Date of Birth / Name(s) of minor child/ren Date of Birth / / / City, State, Zip Defendant's Street Address Relationship of the Parties: Parties shall not be household members as defined by 15 VSA 1101(2). Other Civil/Probate/Juvenile/Criminal Court Proceedings or Orders Involving These Parties: Proceeding Attorney Name of Court State County Pending Order Existing Order Plaintiff's Defendant's Type I. Stalk On more than one occasion, on or about , and the Defendant did (date) (date) the following to Plaintiff Plaintiff's Child(ren), by engaging in the following conduct which served no legitimate purpose and which would cause a reasonable person substantial emotional distress or fear for his or her safety. followed in such a manner as would cause a reasonable person fear of unlawful sexual conduct, unlawful restraint, bodily injury or death. lay in wait for the purpose of attacking or harming. engaged in threatening behavior (acts which would cause a reasonable person to fear unlawful sexual conduct, unlawful restraint, bodily injury, or death, including verbal threats, written, telephonic, or other electronically communicated threats, vandalism, or physical contact without consent.) II. Sexual Assault 1. On or about , the Defendant engaged in the following behavior with (date) A. lewd and lascivious conduct with a child as defined in 13 V.S.A. § 2602 sexual assault as defined in 13 V.S.A. § 3252 aggravated sexual assault as defined in 13 V.S.A. § 3253 AND Plaintiff Plaintiff's Child(ren) use of a child in a sexual performance as defined in 13 V.S.A. § 2822 consenting to a sexual performance as defined in 13 V.S.A. § 2823 and Plaintiff was the victim of the offense There is a danger of further harm to Plaintiff Plaintiff's Child(ren), OR , the Defendant was convicted of sexually assaulting the Plaintiff by committing one of the (date) three offenses set forth in part 1A above. III. REQUEST FOR EMERGENCY RELIEF The Plaintiff requests the court: Order the defendant to refrain from stalking or sexually assaulting the Plaintiff Plaintiff's Child(ren) and to refrain from interfering with his/her/their personal liberty. B. 2. On Stay Away from Plaintiff Plaintiff's child(ren). ("Stay away" means to refrain from initiating or maintaining a physical presence near the plaintiff; engaging in nonphysical contact with the Plaintiff directly or indirectly; engaging in nonphysical contact with the Plaintiff through third parties who may or may not know of the Order. "Nonphysical contact" includes: telephone calls, mail, e-mail or other electronic communication, fax and written notes. ) Other: IV. REQUEST FOR FINAL ORDER The Plaintiff requests the court to order the Defendant to: Stay Away from Plaintiff Plaintiff's child(ren). ("Stay away" means to refrain from initiating or maintaining a physical presence near the Plaintiff; engaging in nonphysical contact with the Plaintiff directly or indirectly; engaging in nonphysical contact with the Plaintiff through third parties who may or may not know of the Order. "Nonphysical contact" includes: telephone calls, mail, e-mail or other electronic communication, fax and written notes. ) Other: The facts to support this request for protection order can be found on Plaintiff's accompanying affidavit. Signature of Plaintiff/Attorney 6/08 SML Distribution: Original ~ Court; 1 Copy ~ Plaintiff; 1 Copy ~ Defendant; 1 Copy ~ File Date American LegalNet, Inc. www.FormsWorkflow.com