INSTRUCTIONS TO THE PLAINTIFF	
	
HARASSMENT PREVENTION ORDERS 

nder chapter 258E of Massachusetts General Laws, people who have suffered harassment may ask a judge to issue an Order to protect them 

from further harassment or abuse.  These Orders will be recorded and enforced by law enforcement agencies.  They are commonly called 
“Harassment Prevention Orders” or “Restraining Orders” or “258E 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 

	
YOU MUST COMPLETE 4 FORMS: 
 

o request a Harassment 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 harassed you is the “Defendant.” 

f either party is under 18.   You are asked to indicate on the form whether you and the Defendant are under 18 years of age because the law 
provides that if either you or the Defendant is under the age of 18, such cases are not open to public inspection and are available only to the 
Plaintiff, the Plaintiff’s attorney, the person under 18, and his or her parent, guardian, and attorney. 

ther prior and/or pending actions.  If there are any prior or pending actions in any state or country between you and the Defendant, please have 

any legal papers you have from such actions with you at the time of the hearing. 

inancial compensation.  You may request that a judge order the Defendant to compensate you for any financial losses suffered as a direct result 

of the harassment.  These may include, but are not limited to, lost earnings, out-of-pocket losses for injuries sustained or property damaged, the 
costs for replacement locks, medical expenses, or obtaining an unlisted phone number, and reasonable attorney’s fees. 

.  AFFIDAVIT 

hen you have completed the Complaint form, you must then complete the form entitled Affidavit.  Describe the details of the harassment.  If the 
harassment consisted only of conduct that was willful and malicious, but was not a violation of the criminal statutes listed on the Complaint form, 
you must describe at least 3 separate incidents of such harassment to be eligible for a Harassment Prevention Order.  Fill out the Affidavit even if 
you are requesting relief after court hours unless a judge directs otherwise. 

.  PLAINTIFF CONFIDENTIAL INFORMATION FORM 

ou must also fill out a Plaintiff Confidential Information Form, which lists your address, telephone number(s), email address, and related 

information.  The information in this form is confidential and this form is not available to the public, the Defendant or the Defendant’s attorney.  
Except with a judge’s permission, this form is available to you, to your attorney, to those you authorize to have access, and to certain persons 
when access is necessary in the performance of their duties (prosecutors, law enforcement officers, victim-witness advocates, and sexual assault 
counselors). 

owever, if you request that the Defendant be ordered to remain away from your residence or work place addresses, 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. 

f 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, and sexual assault counselors), you 
may file a Motion for Impoundment under Trial Court Uniform Rule VIII on Impoundment Procedure. 

ther court records of this matter will generally be open to public inspection.  You may also file a Motion for Impoundment if you have good 
reasons to ask a judge to keep other parts of the court record from public inspection.  Usually a general preference for privacy is not alone a 
sufficient reason for a judge to impound court records from public inspection. 

.  DEFENDANT INFORMATION FORM 

he Plaintiff must also fill out the Defendant Information Form.  Please provide the requested information to the best of your ability in order to 
identify the Defendant and where the 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. 

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04/15/2020	

COMPLAINT FOR PROTECTION FROM HARASSMENT 
G.L. c. 258E

DOCKET NO. 

A  (cid:0)   Boston Municipal Court 

(cid:0)   District Court 

(cid:0)   Juvenile Court 

(cid:0)   Superior Court 

Massachusetts Trial Court
DIVISION 

NAME OF PLAINTIFF (person seeking protection) 

NAME OF DEFENDANT (person accused of harassment) 

B 

D 

E 

I am:                        (cid:0)     18 or older 
 18 or older 
The Defendant is:    (cid:0) 

 (cid:0)   17 
 (cid:0)   17 

 (cid:0)   16 or younger 
  (cid:0)   16 or younger 

Are there any prior or pending actions between the Plaintiff and the 

Defendant?     (cid:0)   NO     (cid:0)   YES 

C 

¨ I am under the age of 18 and ___________________________

If so, list court, type of case, date, and docket no. (if available). 

(name), my _____________________________ (relationship to

Plaintiff), has filed this Complaint on my behalf.

I SUFFERED HARASSMENT WHEN: 

¨ On or about (date(s)) _____________________________________________________________ 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).

THEREFORE, I ASK THE COURT 

¨ 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).

¨ To order the Defendant not to contact me, unless authorized to do so by the Court.

¨ To order the Defendant to remain away from my residence (as listed on the Plaintiff Confidential Information form).

¨ To order the Defendant to remain away from my workplace (as listed on the Plaintiff Confidential Information form).

¨ To order the Defendant to pay me $ ______________ in compensation for the following losses suffered as a direct result of the

harassment:
____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

¨ 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.

Please complete the AFFIDAVIT, the PLAINTIFF 

DATE 

PLAINTIFF’S SIGNATURE 

CONFIDENTIAL INFORMATION form, and the 

DEFENDANT INFORMATION form. 

This is a request for a civil order to protect against future harassment.  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 harassment occurred. 

04/15/2020	

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 three 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.  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, and in any additional pages attached are true. 
DATE SIGNED 

PLAINTIFF’S SIGNATURE 

WITNESSED BY 

PRINTED NAME OF WITNESS 

TITLE OF WITNESS 

If more space is needed, attach additional pages and check this box:  (cid:0) 

(cid:0)  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

04/15/2020	

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. 

04/15/2020	

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) 
 

RACE 

EYES 

HAIR 

HEIGHT 

WEIGHT 

LAST FOUR SOCIAL SECURITY NO. 

XXX – XX –  

PHOTO AVAILABLE (helpful for ID) 
¨  Yes 
¨  No 

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

   

SEX 
¨  MALE 
¨  FEMALE 
BUILD 

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) 

DEPARTMENT 

TITLE 
 

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.) 

ATE 

PRINT PLAINTIFF’S NAME 

PLAINTIFF’S SIGNATURE 

 

04/15/2020	

   

   

   

   

   

     

   

     

   

   

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