| STATE OF RHODE ISLAND |
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FAMILY COURT |
| COUNTY OF _________________________________________ |
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| _________________________________________ |
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| Plaintiff |
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| VS. |
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F.C. NO. ________ |
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| _________________________________________ |
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| Defendant |
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COMPLAINT FOR PROTECTION FROM ABUSE
Pursuant to Chapter 15 of this title, I request that the court enter an order protecting
me from abuse.
(1) My full name, present street address, city, and telephone number are as follows:
_________________________________________
_________________________________________
(2) My former residence, which I have left to avoid abuse, is as follows (street address
and city): _________________________________________
_________________________________________
(3) The full name, present street address, city, and telephone number of the person
causing me abuse (the defendant) are as follows:
_________________________________________
(4) My relationship to the defendant is as follows:
___ We (are) (were formerly) married to one another.
___ I am the defendant's (child) (parent).
___ I am the blood relative or relative by marriage of the defendant; specifically, the
defendant is my ____ .
___ I and the defendant are together the legal parents of one or more children in common.
______ I and the defendant have had a substantive dating or engagement relationship.
___ I am a parent of a minor child(ren) in my care or custody, to which defendant is
not a blood relative or relative by marriage.
(5) On or about ________ , I suffered abuse when the defendant:
___ Threatened or harmed me 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. Specifically, the defendant
_________________________________________
_________________________________________
_________________________________________
_________________________________________
(6) 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.
___ The court order the defendant to immediately leave the household which is located
at
_________________________________________
___ The court award me temporary custody of the following minor child(ren)(the defendant
and I are husband and wife):
| Names |
Date of Birth |
| That _________________________________________ |
| _________________________________________ |
| _________________________________________ |
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 the order is entered on the question of continuing
the temporary order.
(7) I have not sought protection from abuse from any other judge of the family court
arising out of the facts or circumstances alleged in this complaint.
(8) That the court award me support for my minor children as required by law for a
period not to exceed ninety (90) days.
| _________________________________________ |
| (Signature) |
(Date) |
Subscribed and sworn to before me in __________ in the county of ________ in the state of Rhode Island, this _____ day of ________ A.D. 20___ .
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_________________________________________ |
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Notary Public |
Note: If this complaint is filed by an attorney, the attorney's certificate should
appear as below:
ATTORNEY CERTIFICATE
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Signed: _________________________________________ |
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Attorney for Plaintiff |
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Address: _________________________________________ |
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__________ |
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Date: ___________ , 20___ |
| WHITE COPY |
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— Court |
| YELLOW COPY |
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— Plaintiff |
| PINK COPY |
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— Defendant |
| GOLDENROD COPY |
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— Police Department |
(b) A form in substantially the following language shall suffice for the purpose of
requesting temporary orders under this chapter:
| STATE OF RHODE ISLAND |
|
FAMILY COURT |
| COUNTY OF _________________________________________ |
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| _________________________________________ |
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| Plaintiff |
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| VS. |
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F.C. NO. ________ |
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| _________________________________________ |
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| Defendant |
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TEMPORARY ORDER PURSUANT TO CHAPTER 15 OF
THIS TITLE GENERAL LAWS OF RHODE ISLAND
Upon consideration of plaintiff's complaint and having found that immediate and irreparable
injury, loss, or damage will result to the plaintiff before a notice can be served
and a hearing had thereon it is ORDERED:
___ That the defendant is restrained and enjoined from contacting, assaulting, molesting,
or otherwise interfering with plaintiff and any minor children of the plaintiff at
home, on the street, or elsewhere, to wit, _________________________________________
_________________________________________
___ That the defendant vacate forthwith the household located at
_________________________________________
___ That the plaintiff, being the [husband] [wife] of the defendant, be and [s]he hereby
is awarded temporary custody of the minor child[ren], to wit, _________________________________________
_________________________________________ .
___ That the defendant pay to the plaintiff for the support of the minor child(ren) the
sum of $___ per ___ .
___ That _________________________________________
_________________________________________
_________________________________________
A hearing on the continuation of this ORDER will be held at the family court, _______ County, at ____ [A.M.] [P.M.] on ________ . If the defendant wishes to be heard, [s]he will be heard at that time. If [s]he
does not appear at that time, this ORDER shall remain in effect.
This ORDER is effective forthwith, and will remain in effect until the time and date
of the above-mentioned hearing.
A copy of this ORDER shall be transmitted to the appropriate local law enforcement
agency forthwith, and shall be served in-hand on the defendant herein.
ENTERED as an order of court this _____ day of ________ , A.D. 20___ .