Fill - Free fillable Affidavit in Support of Relief from Abuse Complaint (Vermont Judiciary) PDF form

400-00151N – Affidavit in Support of Relief from Abuse Complaint Notary (10/2019) Page 1 of 2

STATE

VERMONT

SUPERIOR COURT

FAMILY DIVISION

Unit

Docket No.

Plaintiff Date Of Birth Defendant Date Of Birth

Defendant’s Full Physical Address: _____________________________________________________________

Affidavit in Support of Relief from Abuse Complaint

In support of the claims made in my complaint, I state the following facts to be true and correct to the best of

my knowledge and belief.

To my knowledge, the defendant ☐ is ☐ is not in possession of a dangerous weapon.

The most recent incident that causes me to ask for an order happened on ___________________ at

(date)

_______________ in the town of _______________________________, in the state of __________________

(time)

When _________________________________ did the following to me and/or the minor children:

(name)

_________________________________________________________________________________________

(attach a separate sheet of paper if necessary)

Is the incident described above the most serious incident involving the defendant? ☐ Yes ☐ No

If you answered NO:

The most serious incident that causes me to ask for an order happened on ___________________ at

(date)

_______________ in the town of _______________________________, in the state of _____________.

(time)

Describe what happened below. (Be specific. Where did it happen? Who else was there? Was a weapon involved?)

____________________________________________________________________________________

(attach a separate sheet of paper if necessary)

400-00151N – Affidavit in Support of Relief from Abuse Complaint Notary (10/2019) Page 2 of 2

Other past incidents of serious violence or threats that support my request for an Order include:

(Be specific. For each incident, state: When and where it happened, who else was there, and details about any injuries resulting or

weapons used.)

___________________________________________________________________________________

(attach a separate sheet of paper if necessary)

Do you feel that you are in immediate danger of further abuse from the defendant? ☐ Yes ☐ No

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

I swear or affirm that the facts set forth in this petition are true and correct to the best of my knowledge and

belief.

Date: ___________________________ Signature: ____________________________________________

Printed Signature: ______________________________________

Signed and sworn to before me:

Date: ___________________________

Expiration Date: ___________________ Signature of Notary: ____________________________________

NOTICE: This Affidavit will be served on Defendant with the Complaint for Relief from Abuse

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Fillable Affidavit in Support of Relief from Abuse Complaint (Vermont Judiciary)

Fill Online, Printable, Fillable, Blank Affidavit in Support of Relief from Abuse Complaint (Vermont Judiciary) Form

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