Form 151m
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STATE OF VERMONT
SUPERIOR COURT
FAMILY DIVISION
Unit
Docket No.
Child’s DOB
Defendant’s Name
DOB
DOB
Defendant’s Street Address
City, State, Zip
AFFIDAVIT IN SUPPORT OF COMPLAINT FOR CHILD
In support of the claims made in my complaint and subject to the penalties for perjury, I state the following facts to be
true to the best of my knowledge and belief.
1. The most recent incident that causes me to ask for an order happened on or about
Date
at
Time
in
Town, State
when
Name of person
did the following to the minor child
named above:
(Describe what happened below. Be specific: What was the act or threat of violence? Where did it happen? Who else was there? Was a weapon
involved? Was the child or anyone else injured? What were the injuries?)
Attach a separate sheet if necessary
2. Is the incident described above the most serious incident involving the defendant? Yes No
If your answer is No, please fill in the following information:
The most serious incident that causes me to ask for an order happened on
Date
at
Time
Form 151m
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in
Town, State
(Describe what happened below. Please be specific: What was the act or threat of violence? Where
did it happen? Who else was there? Was a weapon involved? Was the child or anyone else injured?
What were the injuries?)
Attach a separate sheet if necessary
3. 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.)
Form 151m
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Attach a separate sheet if necessary
4. Do you feel that the child named above is 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 checked yes to either question, please explain why.
5. Is there an existing order or a pending court proceeding involving you, the Defendant and/or the child named in
the complaint? Yes No
If yes, please fill in the information requested below:
Type of Proceeding
Name of Case
Name of Court
And State
Docket Number
And Date Filed
Divorce/Separation
Civil Union Dissolution
Parentage
Relief From Abuse
Protection Order
Criminal
Guardianship
Probate
Juvenile
NOTICE: This Affidavit will be served on Defendant with your Complaint.
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 hereby swear or affirm that the information above is true to the best of my knowledge and belief.
Signature of Plaintiff
Date
Printed Name
Signed and sworn before me:
Date
Signature of Notary Public
Expiration Date