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

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

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400-00151MN – Affidavit in Support of Relief from Abuse Complaint for Child Notary (10/2019) Page 1 of 2
STATE
OF
VERMONT
SUPERIOR COURT
FAMILY DIVISION
Unit
Docket No.
Plaintiff Date Of Birth Defendant Date Of Birth
V.
Defendant’s Full Physical Address: _____________________________________________________________
Name of person filing on behalf of child: _______________________________ Date of Birth: ____________
Affidavit in Support of Relief from Abuse Complaint for Child
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 the minor child named above:
(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)
400-00151MN – Affidavit in Support of Relief from Abuse Complaint for Child 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
Do you believe that the defendant poses a danger to other children in the household? ☐ Yes ☐ No
If you answered YES to either questions, please explain why
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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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Affidavit in Support of Relief from Abuse Complaint (Vermont Judiciary)

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Completed 30 July 2020

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