SUPERIOR COURT Unit Plaintiff(s) STATE OF VERMONT CIVIL DIVISION Docket No. Defendant(s) vs. Complaint for Order Against Stalking or Sexual Assault Plaintiff's Information: Name: __________________________________________ Date of Birth: _______________________ Name(s) of minor child(ren): _____________________ _______________________ _____________________ _______________________ Defendant's 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. STALKING On more than one occasion, on or about __________________ and ___________________, the Defendant purposefully did one or more of the following to: Plaintiff Plaintiff's child(ren): followed, monitored, or surveilled threatened or made threats interfered with property II. 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 100-00247 - Complaint for Order Against Stalking or Sexual Assault (07/2016) American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2  2. On ________________________, the Defendant was convicted of sexually assaulting the Plaintiff. III. REQUEST FOR RELIEF The 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 Plaintiff's accompanying affidavit. Dated _____________________________ ___________________________________ Signature of Plaintiff/Attorney 100-00247 - Complaint for Order Against Stalking or Sexual Assault (07/2016) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com