§ 11-37.2-7. Form of complaint. (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 and Providence Plantations, 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:

History of Section. (P.L. 2009, ch. 239, § 1; P.L. 2009, ch. 240, § 1.)