Affidavit in Support of Request for Emergency Relief from Abuse or Neglect or Exploitation

Requesting emergency relief from any type of abuse of exploitation by an affiant requires the execution of the following affidavit.

Extracted Text for Proper Search

400	-00852 	– Affidavit in Support of Request for Ab	use/Neglect/Exploitation (01	/20	17)  	Page 	1 of 	2 	
     	     	
STATE	 OF	 VERMONT	 	 	
SUPERIOR COURT	 	 	FAMILY	 DIVISION	 	
 	Unit	 	 	Docket No. 	 	
 
Plaintiff	 	Date of 	Birth	  	Defendant	 	Date of 	Birth	 	
    	 	    	 	V.	 	    	 	    	 	
 
 	
Affidavit in Support of Request for Emergency Relief	 	
From	 Abuse	/N	eglect	/E	xploitation	 	
Pursuant to 33	 V.S.A. Chapter 69	 	
 	
In support of the claims made in Plaintiff's request for Emergency Relief from Abuse/Neglect/Exploitation, I 
state the following facts, which are true to the best of my knowledge and belief, about the abusive, neglectful 
or exploitive t	reatment and present situation: 	Specifically describe the facts that support the claim(s) of 	
abuse/neglect/exploitation:	 	
 
The most recent incident 	that causes me to ask for an order happened on __________________	_ at	 	
 	(date)	 	
_______________ in the town	 of _______________________________, in the state of __________________	 	
 	(time)	 	
 
When _________________________________ did the following to me and/or the minor children:	 	
 	(name)	 	
_____________________________________________________________________________	____________	 	
_________________________________________________________________________________________	 	
_________________________________________________________________________________________	 	
_______________________________________________________________	__________________________	 	
(attach a separate sheet of paper if necessary)	 	
 
Is the incident described above 	the most serious incident i	nvolving the defendant?	 	☐	 Yes	 	☐	 No	 	
If you answered NO:	 	
 	The most serious incident that causes me to ask for an order 	happened on ___________________ at	 	
 	(date)	 	
 	_______________ in the town of _______________________________, in the state of	 _____________.	 	
(time)	 	
 	 	
 	Describe what happened below.  	(Be specific.  Where did it happen?  Who else was there?  Was a weapon 	involved?	) 	
 	____________________________________________________________________________________	 	
 	____________________________________________________________________________________	 	
 	________________________________________________________________________	____________	 	
 	____________________________________________________________________________________	 	
 	____________________________________________________________________________________	 	
 	______________________________________________________________________	______________	 	
 	(attach a separate sheet of paper if necessary)