Fillable Name of Child (under 18 years of age) (Vermont Judiciary)

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Name of Child (under 18 years of age) (Vermont Judiciary)

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400-00150CC - Complaint for Relief from Abuse On Behalf of a Child (08/2019) Page 1 of 2
STATE
OF
VERMONT
SUPERIOR COURT
FAMILY DIVISION
Unit
Docket No.
Name of Child (under 18 years of age) Date Of Birth Defendant Date Of Birth
V.
Petitioner’s (filing on behalf of child) Information:
Name: __________________________________________
Date of Birth: ____________________________________
Relationship to Child: ______________________________
Defendant’s Information:
Name: __________________________________________
Street Address: _________________________________________________________________________
Town: __________________________________ State: ____________ Zip: _____________
Complaint For Relief From Abuse On Behalf of a Child
Relationship of the Defendant to the Child
☐ Parent/Guardian
☐ Family Member (describe relationship) ____________________________________
☐ Person who lives or has lived in the household with the child
☐ Child and defendant have or have had a dating relationship
☐ Other (describe relationship) _______________________________________________________________
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:
(date of most serious incident)
☐ Abused the child named above (physically injured or otherwise treated the child named above in a
manner which placed the child’s life, health, development or welfare in jeopardy.)
☐ Defendant is a parent/legal guardian for the child named above and either (1) inflicted physical
punishment out of anger, or (2) physically punished the child named above in an excessive,
unreasonable, or cruel manner.
☐ Stalked the child named above as defined in 12 V.S.A. §5131(6).
☐ Sexually assaulted or sexually abused the child named above as defined in 15 V.S.A. §5131(5).
☐ Attempted to cause or caused physical harm to the child named above.
☐ Placed the child named above in fear of imminent serious physical harm.
400-00150CC - Complaint for Relief from Abuse On Behalf of a Child (08/2019) Page 2 of 2
2. ☐ There is danger of further abuse to ☐ the child ☐ other child(ren) in the household named below:
Name of Child Date of Birth Relationship to Petitioner Relationship to Defendant
_____________________ _______________ ___________________ _____________________
_____________________ _______________ ___________________ _____________________
_____________________ _______________ ___________________ _____________________
3. ☐ Defendant is incarcerated and has been convicted of one of the crimes specified in 15 V.S.A. §1103(c)(1)(B).
4. ☐ The child(ren) named above will be forced to leave his/her current residence and will be without
shelter unless Defendant is ordered to leave the residence located at: _________________________.
The residence is ☐ owned ☐ rented/leased in the name of the ☐ Petitioner filing on behalf of
the child(ren) named above ☐ Defendant ☐ Both ☐ Other
Request for Relief
The Petitioner requests that the court:
☐ order Defendant not abuse child(ren) named above and not interfere with his/her/their personal
liberty.
☐ order Defendant refrain from stalking or sexually abusing the child(ren) named above.
☐ order Defendant vacate immediately the residence (identified in #4 above) and sole possession be
awarded to the Petitioner caring for the child(ren) named above.
☐ order Defendant 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 Petitioner.
☐ order Defendant stay __________ feet away from the child(ren) named above in any way.
☐ order Defendant refrain from contacting the minor child(ren) named above in any way.
☐ award the Petitioner filing the complaint temporary Parental Right and Responsibilities for the
child(ren) named below: (Child(ren) of the Petitioner and Defendant)
Name of Child Date of Birth Relationship to Plaintiff Relationship to Defendant
_____________________ _______________ ___________________ _____________________
_____________________ _______________ ___________________ _____________________
_____________________ _______________ ___________________ _____________________
☐ Other: __________________________________________________________________________
☐ order Defendant’s contact with the child(ren) named above supervised by: _______________ at
______________________________.
☐ order Exchanges of the child(ren) named above for parent child contact take place at
______________________________ supervised by _____________________________.
☐ order Defendant not to take any regulated drug unless it is prescribed to Defendant by a physician or
drink alcohol for at least 8 hours prior to a scheduled contact or during contact with the child(ren)
named above and that Petitioner may cancel scheduled contact if Defendant appears to be under the
influence of intoxicating substances.
☐ order Defendant not physically punish the child(ren) named above in any way.
☐ order Defendant pay temporary child support for the child(ren) named above.
☐ Other:
☐ The Petitioner 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 Petitioner/ Petitioner’s Attorney
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Name of Child (under 18 years of age) (Vermont Judiciary)

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Completed 30 July 2020

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