400-00300 Extreme Risk Petition (05/2018) Page 1 of 1
STATE OF VERMONT
SUPERIOR COURT
FAMILY DIVISION
Unit
Docket No.
Petitioner Respondent Date Of Birth
V.
Respondent’s Full Physical Address: ____________________________________________________________
PETITION FOR EXTREME RISK PROTECTION ORDER
Existing Court Order or Proceedings
Is there an existing order or a pending court proceeding involving the Respondent in this petition?
No Yes No Yes
Relief from Abuse Stalking or Sexual Assault
State(s): __________________________________ County: ________________________________
Docket Number: ___________________________
Facts
On (date) _____________ Respondent did the following:
inflicted or attempted to inflict bodily harm on another
by his/her threats or actions has placed others in reasonable fear of physical harm to themselves
by his/her actions or inactions has presented a danger to persons in his/her care
has threatened or attempted suicide or serious bodily harm
Request for Emergency Relief
The Petitioner requests that the Court prohibit the Respondent from purchasing, possessing, or receiving
a dangerous weapon or having a dangerous weapon within his/her custody or control.
Other: ___________________________________________________________________________
Request for Final Order
The Petitioner requests that the Court prohibit the Respondent from purchasing, possessing, or receiving
a dangerous weapon or having a dangerous weapon within his/her custody or control.
Other: ___________________________________________________________________________
The facts to support this request for relief can be found on the Petitioner’s accompanying affidavit.
Dated
_____________________________ _____________________________________
Signature of Petitioner
_____________________________________
Printed Name of Petitioner
_____________________________________
_____________________________________
Address of Petitioner