100-00247 - Complaint for Order Against Stalking or Sexual Assault (07/2016) Page 1 of 2

STATE OF VERMONT SUPERIOR COURT CIVIL DIVISION

Unit Docket No.

Plaintiff(s) Defendant(s)

vs.

Complaint for Order Against Stalking or Sexual Assault

Plaintiff’s Information: Name: __________________________________________ Date of Birth: _______________________

Name(s) of minor child(ren): _____________________ _______________________ _____________________ _______________________

Defendant’s Information:

Name: __________________________________________ Date of Birth: _______________________ Address: ______________________________________________________________________________

Relationship of the Parties:

☐ Married to each other ☐ Live in same residence (current or past)

☐ Divorced from each other ☐ Sexual relationship (current or past)

☐ Dating each other (current or past)

☐ Other (describe relationship) ___________________________________________________________

☐ Family members (describe relationship) __________________________________________________

Other Civil/Probate/Juvenile/Criminal Court Proceedings or Orders Involving These Parties :

Proceeding: ☐ Pending Order ☐ Existing Order

Name of Court:

County: _________________ State: _____________ Attorney: _____________________________

I. STALKING

☐ On more than one occasion, on or about __________________ and ___________________, the

Defendant purposefully did one or more of the following to:

☐ Plaintiff ☐ Plaintiff’s child(ren):

☐ followed, monitored, or surveilled

☐ threatened or made threats

☐ interfered with property

II. SEXUAL ASSAULT

☐ 1. On or about ______________________, the Defendant sexually assaulted the Plaintiff or the Plaintiff's child(ren) by doing one or more of the following:

☐ lewd and lascivious conduct

☐ lewd and lascivious conduct with a child

☐ sexual assault

☐ aggravated sexual assault

☐ use of a child in a sexual performance

☐ consenting to a sexual performance and Plaintiff was the victim of the offense

100-00247 - Complaint for Order Against Stalking or Sexual Assault (07/2016) Page 2 of 2

☐ 2. On ________________________, the Defendant was convicted of sexually assaulting the Plaintiff.

III. REQUEST FOR RELIEFThe Plaintiff requests the Court:

☐ Order the Defendant to stay away from ________________________________________________

☐ Other:

☐ I am asking for an emergency order before the Defendant is notified and a hearing is held because:

The facts to support this request for protection order can be found on Plaintiff’s accompanying affidavit.

Dated

_____________________________ ___________________________________ Signature of Plaintiff/Attorney