Form 254 STATE OF VERMONT MOTION TO MODIFY/EXTEND/VACATE ORDER AGAINST STALKING OR SEXUAL ASSAULT Vermont Superior Court County Plaintiff's Name Docket Number Date of Birth / / Defendant's Name Date of Birth / VS. Date An Order against stalking or sexual assault was entered in the above case on: The Plaintiff / Defendant requests that this Order of the Court be: Modified as follows: Extended until (date) . Vacated. Affidavit in Support of Request: In support of this request, subject to the penalties for perjury, I state the following facts to be true to the best of my knowledge and belief. Specifically describe the facts that support your request. Signature of Petitioner Date Subscribed and sworn to before me. Signature of Notary Public Date Expiration Date NOTICE! This affidavit will be served on opposing party with the motion to modify/extend/vacate the 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. 9/06 SML Distribution: 1 Copy ~ Court 1 Copy ~ Plaintiff 1 Copy ~ Defendant 1 Copy ~ File American LegalNet, Inc. www.FormsWorkflow.com