Complaint Form For An Order Of Protection From Domestic Violence Page 2
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4STATE OF RHODE ISLAND AND
PROVIDENCE PLANTATIONS
FAMILY COURT
4. The relationship, between Plaintiff(s) and Defendant(s) is as follows. (Check and complete
any that apply.)
_____________________________________________________ is presently married to
_____________________________________________________.
_____________________________________________________
was
married
to
_____________________________________________________.
I or _____________________________________________________ am/is/are a blood
relative(s) or relative(s) by marriage of ________________________________________
who is my or the child(ren)’s _______________________________________________.
I or _________________________________________________________________ and
______________________________________________________________ together are
the legal parents of one (1) or more children.
5. On or about ______________________________________, 20____, I suffered abuse when
__________________________________________________________________ committed the
following acts. (Check and complete any that apply.)
Threatened and or harmed me with the following weapon: _________________________
_______________________________________________________________________.
Attempted to cause me physical harm.
Caused me physical harm.
Placed me in fear of imminent physical harm.
Caused me to engage involuntarily in sexual relations by force, threat of force, or duress.
Stalked, cyberstalked, and/or harassed me.
6. I have no knowledge of the existence of other lawsuits between the parties, including actions
for divorce, separate maintenance, custody of children, restraining orders, or other relief, and I
have not sought a Protective Order from the Family Court or any other court for the same facts or
circumstances alleged in this Complaint, except for the following: ________________________
______________________________________________________________________________
_____________________________________________________________________________.
FC-53 (revised October 2014)
Page 2 of 4
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