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

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

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

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Completed 23 November 2020

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