Post on 09-Aug-2020
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