400-00845 Motion for Emergency Relief (10/2010) Page 1 of 2
STATE OF VERMONT
SUPERIOR COURT
FAMILY DIVISION
Unit
Docket No.
Plaintiff
Defendant
MOTION FOR EMERGENCY RELIEF
I have filed a motion for _________________________ with the Court. In addition to what I have
requested in my motion, I am also requesting that the Court take the following emergency action:
I am asking the Court to schedule a hearing as soon as possible on my motion.
I am asking the Court to immediately issue the following emergency order for the protection of
myself or my children until the Court holds a hearing on my motion:
_______________________________________________________________________________
I am asking the Court to immediately issue the following emergency order for the protection of my
property until the Court hold a hearing on my motion:
_______________________________________________________________________________
SUPPLEMENTAL AFFIDAVIT IN SUPPORT OF EMERGENCY REQUEST
Under penalty of perjury, I hereby swear that the facts I have written below are true to the best of my
knowledge and belief.
1. There is an immediate threat of personal injury to myself or my child? YES NO
If yes, please describe why you believe this is true.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
2. There is an immediate threat of damage or injury to my financial YES NO
Interests of property.
If yes, please describe why you believe this is true.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
400-00845 Motion for Emergency Relief (10/2010) Page 2 of 2
3. Please state any other fact or circumstance which causes you to believe this Court needs to issue
an emergency order or schedule an emergency hearing.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
________________________________ ______________________________________
Date Signature
Signed and sworn to before me:
Date Signature of Notary Public Expiration Date