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__