Complaint Form For An Order Of Protection From Domestic Violence Page 4

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STATE OF RHODE ISLAND AND
PROVIDENCE PLANTATIONS
FAMILY COURT
State of _______________________________
County of _____________________________
On this ________ day of ________________, 20____, before me, the undersigned notary
public, personally appeared _______________________________________________________
 personally known to the notary or  proved to the notary through satisfactory evidence of
identification, which was _________________________________________________, to be the
person who signed above in my presence, and who swore or affirmed to the notary that the
contents of the document are truthful to the best of his or her knowledge.
Notary Public: ____________________________________
My commission expires: ____________________________
Notary identification number: ________________________
ATTORNEY CERTIFICATE
Rhode Island Bar Number:
/s/ ______________________________________________________
Attorney for the Plaintiff
Date:
Office Telephone Number:
FC-53 (revised October 2014)
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