Form 400-00852n - Affidavit In Support Of Request For Emergency Relief From Abuse/neglect/exploitation - Superior Court Of Vermont

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STATE OF VERMONT
SUPERIOR COURT
FAMILY DIVISION
Unit
Docket No.
Plaintiff
Date of Birth
Defendant
Date of Birth
V.
Affidavit 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)
☐ Yes
☐ No
Is the incident described above the most serious incident involving the defendant?
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)
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