TRIAL COURT OF THE COMMONWEALTH

“COMPLAINT FOR PROTECTION FROM HARASSMENT”
“HARASSMENT PREVENTION ORDER”

INSTRUCTIONS FOR POLICE DEPARTMENTS AFTER COURT HOURS

When the court is closed for business, any judge assigned to the Judicial Response System may grant relief to a Plaintiff if the Plaintiff
demonstrates a substantial likelihood of immediate danger of harassment.  “In the discretion of the justice, such relief may be granted and
communicated by telephone to an officer or employee of an appropriate law enforcement agency, who shall record such order on a form
of order promulgated for such use by the chief justice for administration and management and shall deliver a copy of such order on the next
G.L. c. 258E, § 6
court day to the clerk or clerk-magistrate of the court having venue and jurisdiction over the matter.”

INSTRUCTIONS FOR USE OF THIS FORMS PACKAGE

This forms package has been promulgated by the Massachusetts Trial Court’s Chief Justice for Administration and Management
pursuant to G.L. c. 258E, §§ 6 and 11 for use by police departments to record a Harassment Prevention Order issued by a judge over the
telephone when the court is closed for business. Additional supplies of this forms package may be obtained from your local District Court.
Please keep any supplies of these forms under adequate security to prevent misuse.

1. COMPLAINT FOR PROTECTION FROM HARASSMENT.  It is preferable to have the Plaintiff complete and sign the Complaint form
set, if the Plaintiff is able to do so, before contacting a judge. Please print in ballpoint pen and press hard enough so that all four parts
(white, pink, yellow and white) are legible. There are instructions on the back of the form set to which the Plaintiff may refer.

In appropriate circumstances, a judge may issue an Order without the Plaintiff having completed and signed a written Complaint.
If the judge does so, please discard the Complaint form set and advise the Plaintiff that G.L. c. 258E, § 6 requires the Plaintiff to appear
in court on the next court business day to file such a Complaint.

2. AFFIDAVIT.  After the Complaint set has been completed and signed, separate the four parts from the form stub that holds them
together. Turn over the original (white) part and ask the Plaintiff to describe the details of the harassment on the Affidavit form printed
there. When the Affidavit is complete, please indicate by your signature that you have witnessed the Plaintiff’s signature on the Affidavit.
In appropriate circumstances, a judge may dispense with the need for an Affidavit. If the judge does so, leave the Affidavit form

blank.

3. PLAINTIFF CONFIDENTIAL INFORMATION FORM.  Ask the Plaintiff to complete the Plaintiff Confidential Information Form. Seal that

form in an envelope marked “PLAINTIFF’S ADDRESS – CONFIDENTIAL.”

4. DEFENDANT INFORMATION FORM.  Provide the Plaintiff with the Defendant Information Form and ask the Plaintiff to complete it

to the best of his or her ability.

5. HARASSMENT PREVENTION ORDER.  Read or summarize the Complaint and Affidavit over the telephone as requested by the judge.
Please inform the judge if the Plaintiff does not want his or her residence and workplace addresses to appear in the court Order and
thereby to be disclosed to the Defendant. If the judge issues an Order, please complete the Harassment Prevention Order form set,
item by item, as the judge directs. Print in ballpoint pen and press hard enough so that all six parts (white, pink, yellow, blue, green and
white) are legible. Leave the space for “Docket No.” blank, but enter the name and address of the court where the judge makes the
Order returnable. Print your name and police department, and print the name of the judge issuing the Order, in the appropriate spaces.
At the bottom left of the Order, print the name of the “First or Chief Justice” as indicated by the issuing judge. Leave blank the space
where the clerk-magistrate may attest the Order.

6. COLLATING AND DISTRIBUTING COPIES.  Separate the six parts of each page of the Order form set from the form stub that holds
them together. If the Plaintiff has completed the Complaint form, match up and staple together the copies of the Complaint form with
the matching color copies of the Order form: the white (Court) copies, the pink (Plaintiff’s) copies, the yellow (Defendant’s) copies, and
the white (Probation) copies.

Give the pink copies of the Complaint and Order to the Plaintiff.
Deliver the white (Court) copies and the white (Probation) copies of the Complaint and Order on the next business day to the
clerk-magistrate  of  the  court  where  the  Order  is  returnable,  along  with  the  Plaintiff  Confidential  Information  Form  in  a  sealed
envelope and the Defendant Information Form.

Arrange for the yellow copies of the Complaint and Order to be served on the Defendant as soon as possible. If service on the
Defendant cannot be made before the date and time of hearing shown in the Order, service of additional Orders may be necessary.
The two remaining copies of the Order are for police use: the blue copy of the Order is for your records; the green copy of the

Order may be used for the return of service that must be filed with the Court.

HA-3 (5/10)