Fillable FAMILY DIVISION Complaint for Relief from Abuse/Neglect/Exploitation Pursuant (Vermont Judiciary)

Fill Online, Printable, Fillable, Blank FAMILY DIVISION Complaint for Relief from Abuse/Neglect/Exploitation Pursuant (Vermont Judiciary) Form

Use Fill to complete blank online VERMONT JUDICIARY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

FAMILY DIVISION Complaint for Relief from Abuse/Neglect/Exploitation Pursuant (Vermont Judiciary)

On average this form takes 11 minutes to complete

The FAMILY DIVISION Complaint for Relief from Abuse/Neglect/Exploitation Pursuant (Vermont Judiciary) form is 2 pages long and contains:

  • 0 signatures
  • 33 check-boxes
  • 27 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Vermont Judiciary forms online.

BROWSE VERMONT JUDICIARY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
400-00851 – Complaint for Relief from Abuse/Neglect/Exploitation (09/2016) Page 1 of 2
STATE OF VERMONT
SUPERIOR COURT
FAMILY DIVISION
Unit
Docket No.
Complaint for Relief from Abuse/Neglect/Exploitation
Pursuant to 33 V.S.A. Chapter 69
Plaintiff Information:
Name: _________________________________________ Date of Birth: _____________________________
Interested Person’s Information:
Name: _________________________________________ Date of Birth: _____________________________
Address: __________________________________________ Email Address: ____________________________
City/State/Zip: _____________________________________ Daytime Phone: ___________________________
I am: ☐ Agent
☐ Guardian
☐ Dept. of Aging/Disabilities
Defendant Information:
Name: _________________________________________ Date of Birth: _____________________________
Address: __________________________________________ Email Address: ____________________________
City/State/Zip: _____________________________________ Daytime Phone: ___________________________
Attorney Information:
Name: ______________________________________________________________________________________
Address of Attorney: _________________________________ City/State/Zip: ____________________________
Phone Number: _____________________________________
Attorney is: ☐ for Plaintiff
☐ for Interested Person
(To be completed by ‘interested person’ only)
Plaintiff is 18 years of age or older and is a vulnerable adult because he/she:
☐ is a resident of a licensed long-term care facility;
☐ is a resident of a psychiatric hospital or psychiatric unit of a hospital;
☐ has been receiving personal care services for more than one month from a certified home health
agency or from a person or organization that offers personal care; or
☐ regardless of residence or service received; is impaired due to brain damage, infirmities of aging, or a
physical, mental or developmental disability that impairs his/her ability to provide for his/her own care
without assistance or that impairs his/her ability to protect him/herself from abuse, neglect or
exploitation.
Plaintiff
☐ is capable of expressing Plaintiff’s wishes with respect to the Complaint or,
☐ is not capable of expressing Plaintiff’s wishes with respect to the Complaint because
_________________________________________________________________________________
400-00851 – Complaint for Relief from Abuse/Neglect/Exploitation (09/2016) Page 2 of 2
Plaintiff
☐ will attend the hearing
☐ will not attend the hearing.
☐ I request that a Guardian ad Litem be appointed because the Plaintiff is not capable of expressing an
opinion with respect to the petition.
On _______________________________, the Defendant
☐ Abused the Plaintiff, as “abuse” is defined by 33 V.S.A. Section 6902(1).
☐ Neglected the Plaintiff, as “neglected” is defined by 33 V.S.A. Section 6902(7).
☐ Exploited the Plaintiff, as “exploited” is defined by 33 V.S.A. Section 6902(6).
The Plaintiff requests that the court enter an order which includes the following:
☐ an order that the Defendant refrain from abusing Plaintiff.
☐ an order that the Defendant refrain from neglecting Plaintiff.
☐ an order that the Defendant refrain from exploiting Plaintiff.
☐ an order that the Defendant immediately leave the household.
The residence is:
☐ owned in: ☐ Plaintiff’s name only ☐ Defendant’s Name
☐ rented/leased ☐ Both Plaintiff’s & Defendant’s Name
☐ Other: __________________________________________________________________________
How will the vulnerable adult be cared for if the Petition is granted?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
If immediate relief is requested complete the next section.
Otherwise, skip to date & signature
REQUEST FOR EMERGENCY RELIEF - MOTION FOR TEMPORARY ORDER
Plaintiff will suffer serious and irreparable harm to Plaintiff’s physical health or financial interests unless ex
parte relief is granted and therefore requests the Court to order:
☐ the Defendant to refrain from abusing the Plaintiff.
☐ the Defendant to refrain from neglecting the Plaintiff.
☐ the Defendant to refrain from exploiting the Plaintiff.
☐ the Defendant to immediately vacate the household.
Location of Household: ____________________________________________________________
☐ that the court clerk not release Plaintiff’s address to anyone except by Plaintiff’s written permission or
Court order.
☐ Other: __________________________________________________________________________
The facts to support this request for Emergency relief can be found on Plaintiff’s accompanying affidavit.
Dated
_____________________________ ___________________________________
Signature of Plaintiff/Attorney/Interested Person
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

FAMILY DIVISION Complaint for Relief from AbuseNeglectExploitation Pursuant (Vermont Judiciary)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document