| 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.
(1) My full name, present street address, city and telephone number are as follows:
_________________________________________
_________________________________________
(2) My former residence, at which I resided with the defendant, is as follows (street
address and city): _________________________________________
_________________________________________
(3) My former residence is a house
I own _________________________________________
Defendant owns _________________________________________
We jointly own _________________________________________
My former residence is an apartment
There is no lease _________________________________________
My name is on lease and defendant's is not _________________________________________
Defendant's name is on lease and mine is not _________________________________________
Both our names are on lease _________________________________________
(4) The full name, present street address, city and telephone number of the person
causing me abuse (the defendant) are as follows: _________________________________________
_________________________________________
(5) 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
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 _________________________________________
_________________________________________
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.
(7) 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. 20_____ .
______________
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: ___________ , 20__
| |
WHITE COPY |
___ Court |
|
| |
YELLOW COPY |
___ Plaintiff |
|
| |
PINK COPY |
___ Defendant |
|
| |
GOLDENROD COPY |
___ Police Department |
|
| STATE OF RHODE ISLAND |
|
DISTRICT COURT |
| COUNTY OF ________ |
|
______ DIVISION |
| _________________________________________ |
: |
|
| Plaintiff |
: |
|
| |
: |
|
| VS |
: |
NO: |
| |
: |
|
| _________________________________________ |
: |
|
| Defendant |
: |
|
(TEMPORARY) ORDER PURSUANT TO CHAPTER
______ OF THE G.L. OF R.I.
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 at home, on the street or elsewhere.
_____ That the defendant vacate forthwith the household located at
_________________________________________
_________________________________________
A hearing on the continuation of this ORDER will be held at the District Court, __________ County, __________ Division, at __ (A.M.) (P.M.) on __________ . If the defendant wishes to be heard, she/he will be heard at that time. If she/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____ .
ENTER: __________ PER ORDER: __________
Judge __________ Clerk __________
Presented by: _________________________________________
Attorney for Plaintiff
| |
WHITE COPY |
___ Court |
|
| |
YELLOW COPY |
___ Plaintiff |
|
| |
PINK COPY |
___ Defendant |
|
| |
GOLDENROD COPY |
___ Police Department |
|