Fillable Unit Name of Child (under 16 years of (Vermont Judiciary)

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Unit Name of Child (under 16 years of (Vermont Judiciary)

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100-00247SM – Complaint for Order Against Stalking OBO a Child (11/2019) Page 1 of 1
STATE
OF
VERMONT
SUPERIOR COURT
CIVIL DIVISION
Docket No.
Unit
Name of Child (under 16 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: _____________
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) _______________________________________________________________
There is another court case involving the Defendant and Petitioner or the child in the following court:
Name of Court:_____________________ County: _______________ State: ______
C
OMPLAINT FOR ORDER AGAINST STALKING
I. Stalking
☐ On more than one occasion, on or about __________________ and ___________________, the
Defendant purposefully did one or more of the following to the minor child mentioned above:
☐ followed, monitored, or surveilled ☐ threatened or made threats ☐ interfered with property
II. REQUEST FOR RELIEF
The Petitioner requests the Court:
☐ Order the Defendant to stay away from ________________________________________________
☐ Other: ___________________________________________________________________________
___________________________________________________________________________
☐ I am asking for an emergency order before the Defendant is notified and a hearing is held because:
_________________________________________________________________________________
_________________________________________________________________________________
The facts to support this request for protection order can be found on Petitioner’s accompanying affidavit.
D
ated
_____________________________ ___________________________________
Signature of Petitioner/Attorney
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Unit Name of Child (under 16 years of (Vermont Judiciary)

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Completed 30 July 2020

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