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Vermont Affidavit in Support of Complaint Form

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Vermont Affidavit in Support of Complaint Form
Vermont Affidavit in Support of Complaint Form
Form 151
Affidavit: Relief From Abuse
STATE OF VERMONT
FAMILY DIVISION
SUPERIOR COURT
Defendant's Name
Plaintiffs Name
DOB
DOB
V.
Defendant's Street Address
City, State, Zip
AFFIDAVIT IN SUPPORT OF COMPLAINT
In support of the claims made in my complaint and subject to the penalties for perjury, I state the following facts to be
true to the best of my knowledge and belief.
Date
Time
1. The most recent incident that causes me to ask for an order happened on or about
at
Town, State
Name of person
did the following to me and/or the
minor children:
when
in
Date
Time
The most serious incident that causes me to ask for an order happened on
at
Town, State
(Describe what happened below. Please be specific: What was the act or threat of violence Where
did it happen Who else was there Was a weapon involved Were you or anyone else injured
What were the injuries)
in
Unit
Docket No.
/ /
/ /
/ /
AM
PM
(Describe what happened below. Be specific: What was the act or threat of violence Where did it happen Who else was there Was a weapon
involved Were you or anyone else injured What were the injuries)
Attach a separate sheet if necessary
2. Is the incident described above the most serious incident involving the defendant
If your answer is No, please fill in the following information:
Yes
No
/ /
Attach a separate sheet if necessary
Other past incidents of serious violence or threats that support my request for an Order include:
3.
(Be specific. For each incident, state: When and where it happened, who else was there, and details about any injuries resulting or weapons used.)
Vermont Affidavit in Support of Complaint Form
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