100-00247S - Complaint for Order Against Stalking (11/2018) Page 1 of 1

STATE OF VERMONT SUPERIOR COURT CIVIL DIVISION

Unit Docket No.

Plaintiff Defendant

vs.

COMPLAINT FOR ORDER AGAINST STALKING

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. 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