INSTRUCTIONS TO THE PLAINTIFF

ABUSE PREVENTION ORDERS 

Under chapter 209A of Massachusetts General Laws, judges can make Orders to protect people from abuse by family or household members.  
These Orders will be recorded and enforced by law enforcement agencies.  They are commonly called “Abuse Prevention Orders” or “Restraining 
Orders” or “209A Orders.”  In any emergency that occurs after court hours or on weekends, you may ask your local police to put you in contact 
with a judge. 

1. COMPLAINT FORM

CHECKLIST OF FORMS 

To request an Abuse Prevention Order, you must fill out a Complaint form and other appropriate forms.  There is no filing fee.  You are the 
“Plaintiff.”  The person you allege has abused you is the “Defendant.”

Part C:  If either you or the Defendant is under the age of 18, indicate that in Part C.  The law provides that such cases are not open to public 
inspection and are available only to the Plaintiff, the Plaintiff’s attorney, the person under 18, or a parent or guardian of the person under 18.  If 
you and the Defendant are both over 18, court records of this matter will generally be open to public inspection.  If you have good reasons to ask 
the judge to keep other parts of the court record confidential, you may file a written request (a “motion”) asking the judge to do so.  Usually, a 
general preference for privacy is not a sufficient reason to permit court records be kept confidential. 

Part E:  If you answer “Yes,” please have with you any legal papers from any such court proceeding at the time of the hearing. 

Part J:  In number 5, financial losses may include, but are not limited to, lost earnings or support, costs for restoring utilities, replacement costs for 
locks or personal property removed or destroyed, medical and moving expenses, and reasonable attorney’s fees. 

2. AFFIDAVIT

When you have completed the Complaint form, you must then complete the form entitled Affidavit.  Describe the details of the abuse.  When you 
are requesting relief after court hours, you must fill out the Affidavit, unless a judge directs otherwise. 

3. PLAINTIFF CONFIDENTIAL INFORMATION FORM

Enter the appropriate information (address(es), telephone number(s), email address).  The information in this form is accessible only by the 
Plaintiff, those authorized by the Plaintiff, those authorized by statute, and by court order.  However, the Plaintiff’s residential address and 
workplace address shall appear on the Order and be accessible to the Defendant and the Defendant’s attorney unless the Plaintiff specifically 
requests that the information be withheld from the order.  The form is kept by the court, but is not part of the public record. 

4. DEFENDANT INFORMATION FORM

This form describes the Defendant and where Defendant can be found.  If an Order is issued, this information will be used by law enforcement 
officers to locate the Defendant to deliver the Order. 

04/23/2020 

A 

B 

C 

D 

E 

I 

J 

COMPLAINT FOR PROTECTION FROM ABUSE 
G.L. c. 209A

DOCKET NO. 

Boston Municipal 

Court 

District Court

Superior Court

(cid:127) Probate &

Family Court

NAME OF PLAINTIFF (person seeking protection) 

NAME OF DEFENDANT (person accused of abuse)  Defendant’s Alias, if 

Massachusetts Trial Court
DIVISION 

any 

 I am 18 or older.
 I am under the age of 18 and

___________________________________ (name), 
my __________________________ (relationship to 
Plaintiff), has filed this Complaint on my behalf. 

 The Defendant is 18 or older.
To my knowledge, the Defendant possesses the 
following guns, ammunition, firearms identification card, 
and/or license to carry: 
_____________________________________________ 
Are there any prior or pending actions in any state or 
country involving the Plaintiff and the Defendant for 
divorce, annulment, separate support, legal separation, 
or abuse prevention?     (cid:127)   NO     (cid:127)   
If so, list court, type of case, date, and docket no. (if 
available). 

YES 

F 

H 

Sex:    (cid:127)

   M    (cid:127)

   F 

The Defendant and the Plaintiff: 
 Are currently married to each other
 Were formerly married to each other
 Are not married, but are related to each other by blood or marriage;

G 

specifically, the Defendant is my:
_____________________________________ (relationship to Plaintiff)

 Are the parents of one or more children
 Are not related, but live in the same household
 Were formerly members of the same household
 Are or were in a dating or engagement relationship.

Does the Plaintiff have any children under the age of 18?    (cid:127)

  NO    (cid:127)

  YES 

If so, the Plaintiff shall complete the appropriate parts of Page 2. 

On or about (date) _____________________ I suffered abuse when the Defendant: 
 Attempted to cause me physical harm
 Caused me physical harm
THEREFORE, I ASK THE COURT 

(cid:127) Placed me in fear of imminent serious physical harm
(cid:127) Caused me to engage in sexual relations by force, threat, or duress

 1.  To order the Defendant to stop abusing me by harming, threatening, or attempting to harm me physically, or placing me in fear of

imminent serious physical harm, or by using force, threat, or duress to make me engage in sexual relations.

 2.  To order the Defendant not to contact me, unless authorized to do so by the Court.
 3a.  To order the Defendant to leave and remain away from my residence (as listed on the Plaintiff Confidential Information form).
 3b.  To order the Defendant to leave and remain away from my workplace (as listed on the Plaintiff Confidential Information form).
 3c.  To order the Defendant to leave and remain away from my school (as listed on the Plaintiff Confidential Information form).
 4a.  To order that my residential address not appear on the order.
 4b.  To order that my workplace address not appear on the order.
 4c.  To order that my school address not appear on the order.
 5.  To order the Defendant to pay me $ ______________ in compensation for the following losses suffered as a direct result of the

abuse:
____________________________________________________________________________________________________________

 6.  To order the Defendant, who has a legal obligation to do so, to pay temporary support to me.
 7.  To order the relief requested on Page 2 of this Complaint pertaining to my minor child(ren).
 8.  To order the following: 

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

 9.  To order the relief I have requested, except for temporary support for me and/or my child(ren) and for compensation for losses

suffered, without advance notice to the Defendant because there is a substantial likelihood of immediate danger of abuse.

DATE 

PLAINTIFF’S SIGNATURE 

Please complete the AFFIDAVIT, the PLAINTIFF 
CONFIDENTIAL INFORMATION form, and the 
DEFENDANT INFORMATION form. 

This is a request for a civil order to protect against future abuse.  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.  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 where the alleged abuse occurred. 

04/23/2020 

(cid:127)
(cid:127)
(cid:127)
COMPLAINT FOR PROTECTION FROM ABUSE 
G.L. c. 209A (Page 2 of 2)

DOCKET NO. 

Massachusetts Trial Court

ISSUES PERTAINING TO CHILDREN 

A. RELATED PROCEEDINGS.  Is there any proceeding that the Plaintiff knows of or has participated in which is pending or has been

concluded in any Court in the Commonwealth or any other state or country involving the care or custody (including care and protection or
guardianship actions) of the child or children of the parties?       YES       NO

If yes, the Plaintiff shall complete and file with this Complaint an Affidavit Disclosing Care or Custody Proceedings as required by Trial Court
Uniform Rule IV, and provides copies of documents required by the Rule.  This Affidavit and related information are available from the office
of the Clerk Magistrate or Register of Probate of the Court.

B. RELATED PROCEEDINGS.  Are there any prior or pending court actions in any Court in the Commonwealth or in any other state or country

involving the Plaintiff and the Defendant for paternity?       YES       NO

C. CUSTODY.

¨ I request custody of the following minor child(ren) of the parties:

NAME 

AGE 

NAME 

AGE 

D. CONTACT WITH CHILDREN.  I ask the Court to order the Defendant not to contact the following minor child(ren) unless authorized to do

so by the Court:

NAME 

AGE 

NAME 

AGE 

The specific reasons for this request are:  
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________ 

¨ I ask the Court to order the Defendant remain away from the following school(s) and day care(s):  (list names and addresses)

________________________________________________________________________________________________________
________________________________________________________________________________________________________

If the Plaintiff alleges that the Defendant has abused the above-named child(ren), a separate Complaint may be filed on behalf of each 
child. 

E. VISITATION.  If the Plaintiff is filing this Complaint in the Probate and Family Court, the Plaintiff may request a Visitation Order.  Such

Visitation Orders are not available in other Courts.  Regarding visitation, I ask the Court to:

¨ Permit visitation.
¨ Order no visitation between the Defendant and our minor child(ren).
¨ Permit visitation only at the following visitation center:  ____________________________________________________________,

to be paid for by ___________________________________________________________ (name).

¨ Permit only visitation supervised by ___________________________________________________________ (name), at the

following times:  ________________________________, to be paid for by _____________________________________ (name).
¨ Order visitation only if a third party, __________________________________________________ (name), picks up and drops off

________________________________________________________________________________________________________

¨ I ask the Court to order the Defendant, who has legal obligation to do so, to pay temporary support for any children in my custody.

our minor child(ren).

¨ Other

F. TEMPORARY SUPPORT.

DATE 

PLAINTIFF’S SIGNATURE 

04/23/2020	

AFFIDAVIT 

Describe in detail the most recent incidents of abuse.  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 abuse, with as much of the above detail as possible.  Note:  Unless the Court allows a 
motion to impound, this affidavit will be public record, including any names or specific addresses included in the affidavit.

On or about ________________ (date), the Defendant: 

I declare under penalty of perjury that all statements of fact made above, including those provided on P.1, Section E and P.2, Sections A and
B of the Complaint form regarding prior and/or pending court actions, and in any additional pages attached, are true to the best of my 
knowledge. 
DATE SIGNED 

PLAINTIFF’S SIGNATURE 

If more space is needed, attach additional pages and check this box:  (cid:127)  

WITNESSED BY 

PRINTED NAME OF WITNESS 

TITLE OF WITNESS 

If this box is checked, this form was  completed by a
police officer with information provided by the Plaintiff.

SIGNATURE OF OFFICER 

PRINTED NAME/TITLE OF OFFICER 

I have transcribed the above affidavit for the Plaintiff. 
TRANSCRIBER’S SIGNATURE 

PRINTED NAME OF TRANSCRIBER 

 Court Certified Interpreter
 Court Screened Interpreter
 Other:  ________________________
 Remote Translation via Telephone/Video

04/23/2020 

(cid:127)
PLAINTIFF CONFIDENTIAL INFORMATION FORM 
G.L. c. 209A, § 8 or G.L. c. 258E, § 10

DOCKET NO. (for court use only) 

Massachusetts Trial Court

This form should be sealed in an envelope marked “PLAINTIFF’S ADDRESS – CONFIDENTIAL.” 

PLAINTIFF’S NAME 

 PLAINTIFF’S DATE OF BIRTH 

¨ If this box is checked, the Plaintiff requests/requires an interpreter.  Language:  _______________________________________________

PLAINTIFF’S EMAIL ADDRESS 

PLAINTIFF’S CELLPHONE NO. 

PLAINTIFF’S RESIDENTIAL ADDRESS 

PLAINTIFF’S RESIDENTIAL TELELPHONE NO. 

If this is an apartment building or other multiple family dwelling, check here   (cid:0) 
ANY FORMER ADDRESS PLAINTIFF HAS LEFT TO AVOID ABUSE (for G.L. c. 209A abuse prevention cases only) 

ADDRESS OF PLAINTIFF’S WORKPLACE 

PLAINTIFF’S WORKPLACE TELEPHONE NO. 

NAME OF PLAINTIFF’S WORKPLACE 

NAME OF PLAINTIFF’S SCHOOL 

ADDRESS OF PLAINTIFF’S SCHOOL 

PERSONS AUTHORIZED BY PLAINTIFF TO HAVE ACCESS TO THIS CONFIDENTIAL INFORMATION 

DATE 

PLAINTIFF’S SIGNATURE

THIS FORM IS CONFIDENTIAL AND IS NOT AVAILABLE TO THE PUBLIC, THE DEFENDANT, OR THE DEFENDANT’S ATTORNEY. 
Except with a judge’s permission, this form is available only to you, to your attorney, to those you authorize to have access (see above), and to 
certain persons when access is necessary in the performance of their duties (prosecutors, law enforcement officers, victim-witness advocates, 
sexual assault counselors, and, in G.L. c. 209A cases, domestic violence counselors). 

IF A JUDGE ORDERS THE DEFENDANT TO REMAIN AWAY FROM YOUR RESIDENCE, WORKPLACE, OR SCHOOL, THOSE 
ADDRESSES WILL APPEAR IN THE COURT ORDER.  THEY WILL NOT BE AVAILABLE TO THE PUBLIC BUT THEY WILL BE 
DISCLOSED TO THE DEFENDANT.  If you do not want those addresses to appear in the court Order and thereby be disclosed to the 
Defendant, you should specifically request that they be omitted from the court Order. 

If you and the Defendant are both over 18, court records of this matter will generally be open to public inspection.  If you have good reasons to 
ask a judge to keep other parts of the court record from public inspection, ask the Clerk’s or Register’s Office to explain how to file a Motion for 
Impoundment under Trial Court Uniform Rule VIII on Impoundment Procedure.  You may also file a Motion for Impoundment if you have good 
reasons why your addresses or other confidential information in this case should not be disclosed to those who would otherwise have access in 
the course of their duties (prosecutors, law enforcement officers, victim-witness advocates, sexual assault counselors and, in G.L. c. 209A 
cases, domestic violence counselors).  Usually, a general preference for privacy is not alone a sufficient reason for a judge to impound court 
records from public inspection. 

If either you or the Defendant is under 18, other court records of this matter will not be open to public inspection, and will be available only to you 
and the Defendant, and to your attorneys.  They will also be available to the parent or guardian of any party who is under 18. 

04/23/2020	

DEFENDANT INFORMATION FORM 
AS PROVIDED BY PLAINTIFF 
G.L. c. 209A or G.L. c. 258E

DOCKET NO. (for court use only) 

Massachusetts Trial Court

The below information is requested to help police to identify and locate the Defendant in order to serve the Defendant with a copy of any abuse 
prevention or harassment prevention Order that is issued.  Please provide as much information as possible. 
DEFENDANT’S NAME 

DATE OF BIRTH 

DEFENDANT’S CELLPHONE NO. 

DEFENDANT’S EMAIL ADDRESS 

OTHER NAMES USED BY THE DEFENDANT, IF ANY 

PLACE OF BIRTH 

MOTHER’S MAIDEN NAME (FIRST & LAST) 

FATHER'S NAME (FIRST & LAST) 

LAST FOUR SOCIAL SECURITY NO. 

RACE 

EYES 

HAIR 

HEIGHT 

WEIGHT 

SEX 
¨ MALE
¨ FEMALE
BUILD 

OTHER PHYSICAL CHARACTERISTICS (beard, glasses, scars, tattoos, complexion, hairstyle) 

XXX – XX –  

PHOTO AVAILABLE (helpful for ID) 
¨ Yes
¨ No

DEFENDANT’S HOME ADDRESS (NO., STREET, CITY, STATE, ZIP) 

DEFENDANT’S HOME TELEPHONE NO. 

APT. NO. 

FLOOR NO. 

NAME ON DOOR/MAILBOX 

DOES DEFENDANT UNDERSTAND ENGLISH?    (cid:0)   YES    (cid:0)   NO 
IF NOT, WHAT LANGUAGE(S)? 

DEFENDANT’S EMPLOYER/WORKPLACE 

WORK TELEPHONE NO. 

WORK ADDRESS (NO., STREET, CITY, STATE, ZIP) 

TITLE 

DEPARTMENT 

WORK HOURS 

MOTOR VEHICLE LICENSE PLATE 

YEAR 

MAKE 

MODEL 

COLOR 

DOES DEFENDANT HAVE:  (describe very briefly) 

A history of violence toward police officers?

(cid:0)   NO    (cid:0)   YES 

A history of using and/or abusing drugs and/or alcohol?

(cid:0)   NO    (cid:0)   YES  

 What kind? 

Access to or possess guns, ammunition, a license to carry, a FID card?     (cid:0)   NO    (cid:0)   YES 

 What kind? 

Mental health problems?

(cid:0)   NO    (cid:0)   YES 

 What kind? 

ANY OTHER INFORMATION WHICH MIGHT BE HELFPUL IN LOCATING THE DEFENDANT (Include best place and/or time to find, temporary 
residence, friends’ and/or relatives’ houses, etc.) 

DATE 

PRINT PLAINTIFF’S NAME 

PLAINTIFF’S SIGNATURE 

04/23/2020