Free PA-001, Complaint for Protection from Abuse, Rev. 04/06 - Maine

STATE OF MAINE

DISTRICT COURT Location Docket No.

Plaintiff: individually and on behalf of: COMPLAINT FOR PROTECTION FROM ABUSE (19-A M.R.S.A. §§ 4003 et seq.)

on behalf of:

v. Defendant: on behalf of: 1. Plaintiff information: Full name: Gender: Female Male Date of birth: Present street address, city and telephone number: (list only your name if address is to be kept confidential and complete form PA-015, Affidavit for Confidential Address, which can be obtained from the clerk). If different, mailing address: 2. Defendant information: Full name: Gender: Female Male Date of birth: Race: White Black Asian or Pacific Islander American Indian or Alaskan Native Unknown Present street address, city and telephone number: ____________________________________ _____________________________________________________________________________ If different, mailing address:___________________________________________________ 3. Plaintiff's former residence (if different from above), which plaintiff has left to avoid abuse: (street address, city, state): 4. Plaintiff's relationship to the defendant is: spouse; former spouse; father/mother of my child(ren); relative; former or present sexual partner; presently living together. If none of the above, describe relationship: 5. Plaintiff and defendant are the parents of the following child(ren). Name Date of Birth Gender

Present Address

List below where and with whom the child(ren) have lived within the past 5 years. Name and present address of Dates child(ren) lived person child(ren) lived with with that person

Town and State where child(ren) lived with that person

6. The person who has primary physical residence of the above-named child(ren) is 7. Plaintiff has not been involved in any way in, and has no information about, another court case in any state concerning the custody of the child(ren) except as follows: Divorce or Family Matter Action Protective Custody Other (describe what kind of other case) 8. No one other than the parties has physical custody of the child(ren), or claims to have custody or visitation rights with respect to the child(ren), except as follows: 9. Check all of the following that apply: I am in immediate and present danger of abuse by the defendant, and I ask that the court issue a temporary order to protect me without prior notice to the defendant. My child(ren) are in immediate and present danger of abuse by the defendant, and I ask that the court issue a temporary order to protect my minor child(ren) without prior notice to the defendant. I am not asking for a temporary order.
PA-001, Rev. 04/06

10. Answer the following questions: Does defendant have access to a firearm? Yes No Does defendant possess a firearm? Yes Has the defendant ever used a firearm in an intimidating, threatening or abusive way? Yes No If yes, please explain:

No

11. I base my claim for protection from abuse on the following facts: Describe the abuse. State who committed the abuse , when it occurred and who was abused. (If additional space is needed attach another sheet.) ______________________________________________________

12. One or both of the parties are involved in the following related cases: Divorce or Family Matter action Protection from Abuse Criminal Complaint If there are any court orders awarding custody, visitation, etc. for the children or any court orders against the defendant or any actions pending against either the plaintiff or the defendant, give details: Public assistance benefits have been or are now being received for the child(ren) The Department of Human Services has been contacted to set up, review, change or enforce a child support order regarding the child(ren). (If an order has issued, a copy of the order must be attached to this complaint). If either of the above statements is checked, you must send a copy of this complaint to the Department of Human Services, Support Enforcement Division, Central Office Supervisor, State House Station 11, Augusta, ME 04333-0011. 14. To the personal knowledge of the undersigned, Defendant is not in the Military Service of the United States, as defined in Article I of the "Soldiers' and Sailors' Civil Relief Act of 1940" as amended. This fact is evidenced by the following facts as to residence, employment, etc.: THEREFORE, I ASK THE COURT TO: (a) Order the defendant to stop abusing me and my minor child(ren) living in the household. (b) Order the defendant to have no contact with me, directly or indirectly or my minor children. (c) Order the defendant not to enter my separate residence. (d) Order the defendant to refrain from repeatedly, and without reasonable cause, following me or being at, or in the vicinity of, my home, school, business or place of employment. (e) Order the defendant not to possess or use a firearm or dangerous weapon. (f) Give me possession of and order the defendant to leave immediately and not again enter my residence located at: (g) Give me possession of the following personal and household property: 13.

(h) Award me custody of the following child(ren) (names and ages):

(i)

Give the defendant the following visitation rights with the child(ren):

(j)

Order the defendant to receive counseling, to pay support for me and/or our child(ren), pay damages for lost wages or injuries, pay court costs and attorney fees, and enter any other necessary orders. (k) Other relief requested:______________________________________________________ Date: Signature of plaintiff Personally appeared the above named Plaintiff and signed and made oath to the truth of the statements in the above complaint, before me, Date: Clerk / Notary Public / Attorney at Law