Fillable Complaint For Relief From Abuse (Vermont Judiciary)

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Complaint For Relief From Abuse (Vermont Judiciary)

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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: _____________________________________________________________
Complaint For Relief From Abuse
Relationship of the Parties
☐ Spouses ☐ Family Member (describe relationship) __________________
☐ Former Spouses ☐ Other (describe relationship) __________________
☐ Persons who are or have been living together or sharing occupancy
☐ Persons who are or have been engaged in a sexual relationship
☐ Persons who are or have been dating
Existing Court Order or Proceedings
Is there an existing order or a pending court proceeding involving you, the Defendant, and/or the child(ren) in
this Complaint?
No Yes No Yes
Divorce/Separation ☐ ☐ Civil Union Dissolution ☐ ☐
Relief from Abuse ☐ ☐ Criminal ☐ ☐
Parentage ☐ ☐ Guardianship ☐ ☐
Juvenile (DCF) ☐ ☐ Child Support ☐ ☐
State(s) __________________________________ County _____________________________________
Attorney for Plaintiff _______________________ Attorney for Defendant ________________________
Facts
1. ☐ On _____________________ Defendant did the following to:
(date of the most recent incident)
☐ Plaintiff ☐ Child(ren)
Names of Child(ren) ________________________________________________________________
☐ Attempted to cause or caused physical harm.
☐ Placed him/her/them in fear of imminent serious physical harm.
☐ Abused the child(ren) named above (physically injured or otherwise treated the child(ren) in a
manner which placed the child(ren’s) life, health, development or welfare in jeopardy.)
☐ Stalked ☐ Plaintiff and/or ☐ child(ren) named above as defined in 12 V.S.A. 5131(6) on
(date) __________ and (date) __________.
☐ Sexually assaulted ☐ Plaintiff and/or ☐ child(ren) named above as defined in 15 V.S.A. 5131(5)
2. ☐ There is a danger of further abuse to: ☐ Plaintiff and/or ☐ child(ren) named above.
3. ☐ Defendant is incarcerated and has been convicted of one of the crimes specified in 15 V.S.A. 1103
(c)(1)(B).
4. ☐ Plaintiff has been/will be forced from residence and will be without shelter unless Defendant is
ordered to leave the residence located at: _____________________________________________.
It is ☐ owned ☐ rented/leased in: ☐ Plaintiff’s name ☐ Defendant’s name
☐ Both ☐ Other
5. ☐ Plaintiff ☐ Defendant is a recipient of a Reach Up program.
400-00150C - Complaint for Relief from Abuse (07/2019)
400-00150C - Complaint for Relief from Abuse (07/2019) Page 2 of 2
Request for Relief
The Plaintiff requests that the court:
☐ order Defendant to not abuse ☐ Plaintiff and/or ☐ child(ren) named above and not interfere
with his/her/their personal liberty.
☐ order Defendant to refrain from ☐ stalking or ☐ sexually assaulting ☐ Plaintiff and/or
☐ child(ren) named above.
☐ order Defendant to immediately leave the residence (listed in #4) and to order sole possession to
the Plaintiff.
☐ order temporary living expenses for the Plaintiff
☐ order temporary child support
☐ order Defendant to refrain from cruelly treating ☐ the pet(s) of the parties or ☐ the pet(s) of
the child(ren) named above.
☐ award temporary possession and control of any pet(s) owned by the parties or by the child(ren)
named above to the Plaintiff.
☐ ordered Defendant to remain ______ feet away from ☐ Plaintiff and/or ☐ child(ren) named
above.
☐ order that Defendant may not contact ☐ Plaintiff and/or ☐ child(ren) named above in any
way.
☐ award temporary Parental Rights and Responsibilities of the child(ren) named below to Plaintiff or
to other persons. (Child(ren) of the Plaintiff and Defendant)
Name of Child Date of Birth Relationship to Plaintiff Relationship to Defendant
_____________________ _______________ ___________________ _____________________
_____________________ _______________ ___________________ _____________________
_____________________ _______________ ___________________ _____________________
☐ Other: __________________________________________________________________________
☐ The Plaintiff requests on an emergency basis the same relief as requested above, to the extent
available.
The facts to support this request for relief can be found on the Plaintiff’s accompanying affidavit.
Dated
_____________________________ ________________________________________
Signature of Plaintiff/Attorney
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Complaint For Relief From Abuse (Vermont Judiciary)

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Completed 30 July 2020

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