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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400-00151N – Affidavit in Support of Relief from Abuse Complaint Notary (01/2017) 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: _____________________________________________________________
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.
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 (01/2017) 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
Is there an existing order or a pending court proceeding involving you, the defendant and/or the child/ren
name in the complaint?? ☐ Yes ☐ No
If YES, please fill in the information requested below:
Type of Proceeding Name of Case Name of Court & State Docket Number
& Date Filed
Divorce/Separation ___________________ _____________________ __________________
Civil Union ___________________ _____________________ __________________
Dissolution Parentage ___________________ _____________________ __________________
Relief from Abuse ___________________ _____________________ __________________
Protection Order ___________________ _____________________ __________________
Criminal __________________ ___________________ ________________
Guardianship ___________________ _____________________ __________________
Probate ___________________ _____________________ __________________
Juvenile ___________________ _____________________ __________________
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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