Form 400-00852n - Affidavit In Support Of Request For Emergency Relief From Abuse/neglect/exploitation - Superior Court Of Vermont Page 2

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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
400-00852N – Affidavit in Support of Request for Abuse/Neglect/Exploitation (01/2017)
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