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Complaint For Protection From Harassment HA-1 - Massachusetts
| Complaint For Protection From Harassment Form. This is a Massachusetts form and can be used in Abuse Or Harrasment Prevention Orders State District Court Statewide . |
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COMPLAINT FOR PROTECTION FROM HARASSMENT G.L. c. 258E A DOCKET NO. (for court use only) Massachusetts Trial Court G BOSTON MUNICIPAL COURT G DISTRICT COURT G JUVENILE COURT G SUPERIOR COURT DIVISION NAME OF PLAINTIFF (person seeking protection) NAME OF DEFENDANT (person accused of harassment) B I am: The Defendant is: C G 18 or older G G 18 or older G 17 17 G 16 or younger G 16 or younger Are there any prior or pending actions between the plaintiff and the defendant? G NO G YES If so, list court, type of case, date and docket no. (if available) G I am under the age of 18 and _________________, my _________________________ (relationship to Plaintiff), has filed this Complaint for me. I SUFFERED HARASSMENT WHEN: G D on or about (dates) _____________________________________________ the Defendant committed 3 or more acts of willful and malicious conduct aimed at me which were committed with the intent to cause fear, intimidation, abuse or damage to property and did in fact cause fear, intimidation, abuse or damage to property. on or about (date) ___________________________ the Defendant by force, threat or duress caused me to involuntarily engage in sexual relations. on or about (date) ___________________________ the Defendant committed against me an act that constitutes a violation of one of the following statutes: G.L. c. 265, §§ 13B, 13F or 13H (indecent assault and battery), 22 or 22A (rape), 23 (statutory rape), 24 or 24B (assault with intent to rape), 26C (enticing a child), 43 (criminal stalking) or 43A (criminal harassment), or G.L. c. 272, § 3 (drugging for sexual intercourse). G G THEREFORE, I ASK THE COURT: G 1. to order the Defendant not to abuse me by physically harming me, attempting to physically harm me, or placing me in fear of imminent serious physical harm, and to stop harassing me (1) by any willful and malicious conduct aimed at me and intended to cause fear, intimidation, abuse or damage to property, or (2) by using force, threat or duress to make me engage in sexual relations unwillingly, or (3) by committing against me any act that constitutes a violation of any of the following statutes: G.L. c. 265, §§ 13B, 13F or 13H (indecent assault and battery), 22 or 22A (rape), 23 (statutory rape), 24 or 24B (assault with intent to rape), 26C (enticing a child), 43 (criminal stalking) or 43A (criminal harassment), or G.L. c. 272, § 3 (drugging for sexual intercourse). 2. to order the Defendant not to contact me, unless authorized to do so by the Court. 3. to order the Defendant to remain away from my residence (as listed on the PLAINTIFF CONFIDENTIAL INFORMATION form). 4. to order the Defendant to remain away from my workplace (as listed on the PLAINTIFF CONFIDENTIAL INFORMATION form). 5. to order the Defendant to pay me $ ____________ in compensation for the following losses suffered as a direct result of the harassment: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________. 6. to order the relief I have requested, except for compensation for losses suffered, without advance notice to the Defendant because there is a substantial likelihood of immediate danger of harassment. I understand that, if the Court issues such a temporary Order, the Court will schedule a hearing within 10 court business days to determine whether such a temporary Order should be continued, and I must appear in court on that day if I wish the Order to be continued. DATE PLAINTIFF'S SIGNATURE E G G G G G Please complete the AFFIDAVIT on the reverse of this page, the PLAINTIFF CONFIDENTIAL INFORMATION form, and the DEFENDANT INFORMATION form. x This is a request for a civil order to protect the Plaintiff from future abuse or harassment. The actions of the Defendant may also constitute a crime subject to criminal penalties. For information about filing a criminal complaint, you may talk with the District Attorney's Office for the location where the alleged harassment occurred. HA-1 (5/10) American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT Describe in detail the most recent incidents of harassment. If the harassment consisted only of conduct that was willful and malicious but was not a violation of the listed criminal statutes, you must describe at least 3 separate incidents of such harassment. The judge requires as much information as possible, such as what happened, each person's actions, the dates, locations, any injuries, and any medical or other services sought. Also, describe any history of harassment, with as much of the above detail as possible. On or about , 20 , the Defendant _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________
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