(a) A form in substantially the following language shall suffice for the purpose of filing a complaint under this chapter: 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 (b) A form in substantially the following language shall suffice for the purpose of requesting temporary orders under this chapter: STATE OF RHODE ISLAND DISTRICT COURT COUNTY OF __________ DIVISION _________________________________________ : Plaintiff: VS: NO:
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