STATE OF RHODE ISLAND DISTRICT COURT
COUNTY OF __________ DIVISION
_______________________________________________________________________
Plaintiff:
VS: NO:
_______________________________________________________________________ :
Defendant:
COMPLAINT FOR PROTECTION FROM ABUSE
Pursuant to chapter 8.1 of title 8, I request that the court enter an order protecting
me from abuse.
(a)(1) My full name, present street address, city and telephone number are as follows:
_________________________________________
(b)(2) The full name, present street address, city and telephone number of the person
causing me abuse (the defendant) are as follows:
_________________________________________
(c)(3) On or about __________ , without cause or provocation, I suffered abuse when the defendant:
[ ] Threatened or harmed with a weapon: __________ (type of weapon used)
[ ] Attempted to cause me physical harm;
[ ] Caused me physical harm;
[ ] Placed me in fear of imminent physical harm;
[ ] Caused me to engage involuntarily in sexual relations by force, threat of force
or duress;
[ ] Attempted to cause me to engage involuntarily in sexual relations by force, threat
of force or duress;
Specifically, the defendant: _________________________________________
_________________________________________
(d) I ask that:
[ ] The court order that the defendant be restrained and enjoined from contacting,
assaulting, molesting or otherwise interfering with the plaintiff at home, on the
street or elsewhere.
[ ] I request that the above relief be ordered without notice because it clearly appears
from specific facts shown by affidavit or by the verified complaint that I will suffer
immediate and irreparable injury, loss or damage before notice can be served and a
hearing had thereon. I understand that the court will schedule a hearing no later
than twenty-one (21) days after such order is entered on the question of continuing
such temporary order.
(e) I have not sought protection from abuse from any other judge of the district court
arising out of the same facts or circumstances alleged in this complaint.
_________________________________________
(Signature) (Date)
Subscribed and sworn to before me in __________ in the County of ______ in the State of Rhode Island, this ______ day of _______ A.D. _________
Notary Public
Note: If this complaint is filed by an attorney, the attorney's certificate should
appear below:
ATTORNEY CERTIFICATE
Signed: _________________________________________
Attorney for Plaintiff
Address: _________________________________________
_________________________________________
Date: _______________________________________________________________________
WHITE COPY [ ] Court
YELLOW COPY [ ] Plaintiff
PINK COPY [ ] Defendant
GOLDENROD COPY [ ] Police Department