Fillable ffidavit in Support of Request for Emergency Relief (Vermont Judiciary)

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ffidavit in Support of Request for Emergency Relief (Vermont Judiciary)

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400-00852N – Affidavit in Support of Request for Abuse/Neglect/Exploitation (01/2017) Page 1 of 2
STATE OF VERMONT
SUPERIOR COURT
FAMILY DIVISION
Unit
Docket No.
Plaintiff Date of Birth Defendant Date of Birth
V.
A
ffidavit in Support of Request for Emergency Relief
From Abuse/Neglect/Exploitation
Pursuant to 33 V.S.A. Chapter 69
In support of the claims made in Plaintiff's request for Emergency Relief from Abuse/Neglect/Exploitation, I
state the following facts, which are true to the best of my knowledge and belief, about the abusive, neglectful
or exploitive treatment and present situation: Specifically describe the facts that support the claim(s) of
abuse/neglect/exploitation:
The most recent incident that causes me to ask for an order happened on ___________________ at
(date)
_______________ in the town of _______________________________, in the state of __________________
(time)
When _________________________________ did the following to me and/or the minor children:
(name)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
(attach a separate sheet of paper if necessary)
Is the incident described above the most serious incident involving the defendant? ☐ Yes ☐ No
If you answered NO:
The most serious incident that causes me to ask for an order happened on ___________________ at
(date)
_______________ in the town of _______________________________, in the state of _____________.
(time)
Describe what happened below. (Be specific. Where did it happen? Who else was there? Was a weapon involved?)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
(attach a separate sheet of paper if necessary)
400-00852N – Affidavit in Support of Request for Abuse/Neglect/Exploitation (01/2017) Page 2 of 2
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.)
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
(attach a separate sheet of paper if necessary)
Is there an existing order or a pending court proceeding involving you or the defendant? ☐ Yes ☐ No
If YES, please fill in the information requested below:
Type of Proceeding Name of Case Name of Court & State Docket Number
Divorce/Separation ___________________ _____________________ __________________
Civil Union ___________________ _____________________ __________________
Dissolution Parentage ___________________ _____________________ __________________
Relief from Abuse ___________________ _____________________ __________________
Protection Order ___________________ _____________________ __________________
Criminal __________________ ___________________ ________________
Guardianship ___________________ _____________________ __________________
Probate ___________________ _____________________ __________________
Juvenile ___________________ _____________________ __________________
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 swear or affirm that the facts set forth in this petition are true and correct to the best of my knowledge and
belief.
Date: ___________________________ Signature: ____________________________________________
Printed Signature: ______________________________________
Signed and sworn to before me:
Date: ___________________________
Expiration Date: ___________________ Signature of Notary: ____________________________________
NOTICE: This Affidavit will be served on Defendant with the Complaint for Relief from
Abuse/Neglect/Exploitation
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ffidavit in Support of Request for Emergency Relief (Vermont Judiciary)

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Completed 30 July 2020

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