Vermont Affidavit in Support of Complaint FormVermont Affidavit in Support of Complaint Form
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Form 151
Affidavit: Relief From Abuse

SUPERIOR COURT

STATE OF VERMONT

FAMILY DIVISION

Docket No.

Unit
DOB

Plaintiffs Name

/

V.

DOB

Defendant's Name

/

/

/

City, State, Zip

Defendant's Street Address

AFFIDAVIT IN SUPPORT OF COMPLAINT
In support of the claims made in my complaint and subject to the penalties for perjury, I state the following facts to be
true to the best of my knowledge and belief.
1. The most recent incident that causes me to ask for an order happened on or about

in

Town, State

when

Name of person

Time

Date

/

/

AM
PM

at

did the following to me and/or the
minor children:

(Describe what happened below. Be specific: What was the act or threat of violence? Where did it happen? Who else was there? Was a weapon
involved? Were you or anyone else injured? What were the injuries?)

Attach a separate sheet if necessary

2. Is the incident described above the most serious incident involving the defendant?

Yes

No

If your answer is No, please fill in th